Provider Demographics
NPI:1235213968
Name:VASELAKOS, W DOUGLAS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:W DOUGLAS
Middle Name:
Last Name:VASELAKOS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 RAVINIA PL
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3700
Mailing Address - Country:US
Mailing Address - Phone:708-226-0010
Mailing Address - Fax:708-226-0040
Practice Address - Street 1:700 RAVINIA PL
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-3700
Practice Address - Country:US
Practice Address - Phone:708-226-0010
Practice Address - Fax:708-226-0040
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006093103TC0700X, 102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001622805OtherBLUECROSS PROVIDER NUMBER
IL364250769OtherTAX IDENTIFICATION NUMBER
IL599100Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER