Healthcare Provider Details

I. General information

NPI: 1619300605
Provider Name (Legal Business Name): LISA WALKER LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. LISA WALLACE

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20200 GOVERNORS DR 107
OLYMPIA FIELDS IL
60461-1032
US

IV. Provider business mailing address

5401 RAPIDAN CT
LOTHIAN MD
20711-5724
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number180.008731
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.008731
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC11094
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.008731
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: