Provider Demographics
NPI:1669627576
Name:TEVENAN, JULIE ANNE (LSW)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANNE
Last Name:TEVENAN
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ROUND LAKE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60073-3000
Mailing Address - Country:US
Mailing Address - Phone:847-377-8855
Mailing Address - Fax:
Practice Address - Street 1:121 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:ROUND LAKE PARK
Practice Address - State:IL
Practice Address - Zip Code:60073-3000
Practice Address - Country:US
Practice Address - Phone:847-377-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-19
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149-012818101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149-012818OtherLICENSE