MEDICARE: LISA SCHWAB, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1194193235
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LISA SCHWAB, LLC

Provider Business Mailing Address
First Line	:	4211 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-712-7996
Fax Number	:

Provider Business Practice Location Address
First Line	:	4211 N PROSPECT RD
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-7754
Country	:	US
Telephone Number	:	309-691-5502
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA SCHWAB
Credential	:
Telephone Number	:	309-691-5502

Provider Enumeration Date	:	09/07/2015
Last Update Date	:	04/13/2020

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