Healthcare Provider Details

I. General information

NPI: 1811985468
Provider Name (Legal Business Name): LISA R. BALLINGER M.A., LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2512 HURST DR STE 120
MATTOON IL
61938-9200
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801-2500
US

V. Phone/Fax

Practice location:
  • Phone: 217-258-7590
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180003520
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180003520
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: