Healthcare Provider Details

I. General information

NPI: 1376768374
Provider Name (Legal Business Name): LISA SANDLUND PSY.D., L.C.S.W
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1541 E FABYAN PKWY SUITE 100
GENEVA IL
60134-4105
US

IV. Provider business mailing address

1541 E FABYAN PKWY SUITE 100
GENEVA IL
60134-4105
US

V. Phone/Fax

Practice location:
  • Phone: 630-845-9644
  • Fax:
Mailing address:
  • Phone: 630-845-9644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number071008481
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149012405
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: