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General NPI Number Information
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NPI Number | 1194069153
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Entity Type | Individual
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Provider Name | LISA BRASCH LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 4085 N BROADWAY ST
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City | CHICAGO
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State | IL
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Zip | 60613-2117
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Country | US
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Telephone | 773-883-9100
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Fax |
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Provider Business Mailing Address
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Address Line | 1055 W GRANVILLE AVE APT 909
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City | CHICAGO
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State | IL
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Zip | 60660-5208
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Country | US
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Telephone | 773-554-1710
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 149007659
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License Number State | IL
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