Healthcare Provider Details

I. General information

NPI: 1588071658
Provider Name (Legal Business Name): LISA KHERWISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 BELOIT AVE
BRIDGEVIEW IL
60455-2180
US

IV. Provider business mailing address

9201 BELOIT AVE
BRIDGEVIEW IL
60455-2180
US

V. Phone/Fax

Practice location:
  • Phone: 708-275-5364
  • Fax:
Mailing address:
  • Phone: 708-275-5364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number178.010152
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: