MEDICARE: DR. LISA N DWORKIN-CANTOR

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	103TC0700X	Clinical Psychologist	071005338	IL

General Provider Information

NPI Number	:	1457684144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA N DWORKIN-CANTOR

Provider Business Mailing Address
First Line	:	2521 N BERNARD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-1201
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3322 N ASHLAND AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60657-0195
Country	:	US
Telephone Number	:	773-472-8587
Fax Number	:

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

Provider Enumeration Date	:	09/11/2009
Last Update Date	:	11/08/2021

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