Healthcare Provider Details

I. General information

NPI: 1467238600
Provider Name (Legal Business Name): LISA ELENA MASH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2515 N CLARK ST
CHICAGO IL
60614-2730
US

IV. Provider business mailing address

2604 N SPRINGFIELD AVE UNIT 1
CHICAGO IL
60647-1031
US

V. Phone/Fax

Practice location:
  • Phone: 800-543-7362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071011007
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number071011007
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: