Healthcare Provider Details

I. General information

NPI: 1487694881
Provider Name (Legal Business Name): LISA GUMINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202N 75TH ST # 228
DOWNERS GROVE IL
60516-4274
US

IV. Provider business mailing address

1202N 75TH ST # 228
DOWNERS GROVE IL
60516-4274
US

V. Phone/Fax

Practice location:
  • Phone: 630-247-7172
  • Fax: 630-281-5904
Mailing address:
  • Phone: 630-247-7172
  • Fax: 630-281-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number147000802
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: