Provider Demographics
NPI:1609390962
Name:VANDER LAAN, BETTY
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:
Last Name:VANDER LAAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15746 CHURCH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1540
Mailing Address - Country:US
Mailing Address - Phone:708-309-5724
Mailing Address - Fax:
Practice Address - Street 1:817 DEMPSTER STREET
Practice Address - Street 2:JUNG CENTER
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:312-787-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-28
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012016101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional