MEDICARE: LISA JANE WIESE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149014977	IL

General Provider Information

NPI Number	:	1124410675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JANE WIESE LCSW

Provider Business Mailing Address
First Line	:	2020 N MOZART ST APT 221
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-3977
Country	:	US
Telephone Number	:	773-632-8675
Fax Number	:

Provider Business Practice Location Address
First Line	:	2950 W CHICAGO AVE
Second Line	:	SUITE 202
City	:	CHICAGO
State	:	IL
Zip	:	60622-4375
Country	:	US
Telephone Number	:	773-632-8675
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2015
Last Update Date	:	02/20/2015

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