Provider Demographics
NPI:1942557525
Name:VANNE, BETHANY (LCPC)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:VANNE
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 1:3716 W BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2938
Mailing Address - Country:US
Mailing Address - Phone:309-692-7755
Mailing Address - Fax:309-692-2262
Practice Address - Street 1:3716 W BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2938
Practice Address - Country:US
Practice Address - Phone:309-692-7755
Practice Address - Fax:309-692-2262
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008327101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1245454313OtherNPI - GROUP - JOHN R. DAY AND ASSOCIATES
IL371154942OtherTEIN - TAX IDENTIFICATION NUMBER FOR EMPLOYER
IL366380OtherMEDICARE, PTAN