Healthcare Provider Details

I. General information

NPI: 1043770852
Provider Name (Legal Business Name): ALISA GAYLE FISHMAN RUBIN LCSW, ACM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALISA FISHMAN

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 WAUKEGAN RD STE 100
BANNOCKBURN IL
60015-1885
US

IV. Provider business mailing address

2650 RIDGE AVE STE 1223
EVANSTON IL
60201-1700
US

V. Phone/Fax

Practice location:
  • Phone: 847-444-5300
  • Fax: 847-267-1429
Mailing address:
  • Phone: 847-982-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number73690
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149025724
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: