Healthcare Provider Details

I. General information

NPI: 1710482542
Provider Name (Legal Business Name): MS. LANISHA BLOCKMON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2018
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 SKOKIE BLVD STE 402
NORTHBROOK IL
60062-2820
US

IV. Provider business mailing address

9321 S CLYDE AVE
CHICAGO IL
60617-3745
US

V. Phone/Fax

Practice location:
  • Phone: 847-607-1589
  • Fax: 847-999-4460
Mailing address:
  • Phone: 773-853-6694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.018856
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: