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General NPI Number Information
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NPI Number | 1124410675
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Entity Type | Individual
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Provider Name | LISA JANE WIESE LCSW
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Gender | Female
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Dates
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Enumeration Date | 02/20/2015
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Last Update Date | 02/20/2015
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Provider Practice Location Address
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Address Line | 2950 W CHICAGO AVE SUITE 202
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City | CHICAGO
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State | IL
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Zip | 60622-4375
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Country | US
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Telephone | 773-632-8675
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Fax |
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Provider Business Mailing Address
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Address Line | 2020 N MOZART ST APT 221
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City | CHICAGO
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State | IL
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Zip | 60647-3977
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Country | US
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Telephone | 773-632-8675
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 149014977
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License Number State | IL
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