Provider Demographics
NPI:1467293043
Name:VIDOVIC, LUKE W
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:W
Last Name:VIDOVIC
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15336 OROGRANDE CT
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-1766
Mailing Address - Country:US
Mailing Address - Phone:708-382-1649
Mailing Address - Fax:
Practice Address - Street 1:520 E 22ND ST
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6110
Practice Address - Country:US
Practice Address - Phone:708-413-0787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178020187101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty