Provider Demographics
NPI:1265637326
Name:VASILENKO, ROXANNE FAUROT (LCSW)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:FAUROT
Last Name:VASILENKO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:FAUROT
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:17746 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3936
Mailing Address - Country:US
Mailing Address - Phone:708-444-1012
Mailing Address - Fax:708-614-9449
Practice Address - Street 1:17746 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3936
Practice Address - Country:US
Practice Address - Phone:708-444-1012
Practice Address - Fax:708-614-9449
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial Worker
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL705120Medicare ID - Type Unspecified