Provider Demographics
NPI:1275815508
Name:VYAZOVSKY, VERONICA D (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:VERONICA
Middle Name:D
Last Name:VYAZOVSKY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 LAVERGNE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2026
Mailing Address - Country:US
Mailing Address - Phone:312-799-9351
Mailing Address - Fax:
Practice Address - Street 1:4700 OLD ORCHARD RD
Practice Address - Street 2:APT 211
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1061
Practice Address - Country:US
Practice Address - Phone:312-799-9351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-13
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008516101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid