Healthcare Provider Details

I. General information

NPI: 1194069153
Provider Name (Legal Business Name): LISA BRASCH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 11/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4085 N BROADWAY ST
CHICAGO IL
60613-2117
US

IV. Provider business mailing address

1055 W GRANVILLE AVE APT 909
CHICAGO IL
60660-5208
US

V. Phone/Fax

Practice location:
  • Phone: 773-883-9100
  • Fax:
Mailing address:
  • Phone: 773-554-1710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number149007659
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: