Provider Demographics
NPI:1255771127
Name:WOLTERS, VANESSA MAE
Entity type:Individual
Prefix:MS
First Name:VANESSA
Middle Name:MAE
Last Name:WOLTERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 HASSELL RD APT 301
Mailing Address - Street 2:
Mailing Address - City:HOFFMAN ESTATES
Mailing Address - State:IL
Mailing Address - Zip Code:60169-2242
Mailing Address - Country:US
Mailing Address - Phone:269-363-5081
Mailing Address - Fax:
Practice Address - Street 1:1414 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-3902
Practice Address - Country:US
Practice Address - Phone:708-681-0073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010944101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health