Healthcare Provider Details

I. General information

NPI: 1427463405
Provider Name (Legal Business Name): LISA WALLACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2014
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20200 GOVERNORS DR 107
OLYMPIA FIELDS IL
60461-1032
US

IV. Provider business mailing address

1835 W 34TH ST
STEGER IL
60475-1499
US

V. Phone/Fax

Practice location:
  • Phone: 708-462-4235
  • Fax:
Mailing address:
  • Phone: 708-906-0205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number180.008731
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180.008731
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number180.008731
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.008731
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number180.008731
License Number StateIL
# 6
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.008731
License Number StateIL

VIII. Authorized Official

Name: LISA WALLACE
Title or Position: PROVIDER
Credential: LCPC
Phone: 708-906-0205