Provider Demographics
NPI:1134710825
Name:VANDER, TONYA (LSW)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:VANDER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:TONYA
Other - Middle Name:M
Other - Last Name:VANDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:6301 N TALMAN AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1818
Mailing Address - Country:US
Mailing Address - Phone:312-213-6244
Mailing Address - Fax:
Practice Address - Street 1:3412 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2365
Practice Address - Country:US
Practice Address - Phone:708-990-8221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0230131041C0700X
IL150.103788104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1275005670OtherPSYCHEALTH SERVICES