Provider Demographics
NPI:1750644688
Name:MENON, VINITA (PHD)
Entity Type:Individual
Prefix:DR
First Name:VINITA
Middle Name:
Last Name:MENON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4N204 FOX MILL BLVD
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60175-7768
Mailing Address - Country:US
Mailing Address - Phone:630-222-4957
Mailing Address - Fax:
Practice Address - Street 1:1400 STATE ST
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-4735
Practice Address - Country:US
Practice Address - Phone:815-421-9010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-15
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2391453103TS0200X
IL071.008186103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool