Provider Demographics
NPI:1356408454
Name:VAN ERON, KEVIN JOSEPH (PSYD, LCP)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:JOSEPH
Last Name:VAN ERON
Suffix:
Gender:M
Credentials:PSYD, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:53 W JACKSON BLVD
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3606
Mailing Address - Country:US
Mailing Address - Phone:312-593-6791
Mailing Address - Fax:312-356-9961
Practice Address - Street 1:53 W JACKSON BLVD
Practice Address - Street 2:SUITE 1111
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3606
Practice Address - Country:US
Practice Address - Phone:312-593-6791
Practice Address - Fax:312-356-9961
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-007046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216684Medicare PIN