Healthcare Provider Details

I. General information

NPI: 1225515794
Provider Name (Legal Business Name): LISA BERREMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 GOLF RD STE 1100
SKOKIE IL
60076-1249
US

IV. Provider business mailing address

806 EAGAN OAKS LN
EAGAN MN
55123-2467
US

V. Phone/Fax

Practice location:
  • Phone: 847-933-9339
  • Fax:
Mailing address:
  • Phone: 651-428-4581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number11240303-2501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: