Healthcare Provider Details

I. General information

NPI: 1386786135
Provider Name (Legal Business Name): LISA LYNN WARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 W PARK AVE
CHAMPAIGN IL
61820-3929
US

IV. Provider business mailing address

38 CARRIAGE PL
URBANA IL
61802-2153
US

V. Phone/Fax

Practice location:
  • Phone: 217-373-2428
  • Fax:
Mailing address:
  • Phone: 217-898-3821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: