Provider Demographics
NPI:1720359441
Name:VAN TIL, DOUGLAS (LCSW)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:VAN TIL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15127 S 73RD AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-4398
Mailing Address - Country:US
Mailing Address - Phone:708-845-5500
Mailing Address - Fax:708-845-5505
Practice Address - Street 1:24755 S COUNTRY LN
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2658
Practice Address - Country:US
Practice Address - Phone:800-361-6880
Practice Address - Fax:708-845-5500
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0012561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical