Healthcare Provider Details

I. General information

NPI: 1386991560
Provider Name (Legal Business Name): LISA ANN BANNER M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W 5TH AVE 205I
NAPERVILLE IL
60563-8965
US

IV. Provider business mailing address

36 N SPRING AVE
LA GRANGE IL
60525-5922
US

V. Phone/Fax

Practice location:
  • Phone: 630-779-0751
  • Fax: 630-753-0942
Mailing address:
  • Phone: 630-254-4805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1800075791
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2442773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: