MEDICARE: LISA TAMAR PROVORNY L.C.P.C.

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	101Y00000X	Counselor	180011361	IL

General Provider Information

NPI Number	:	1518354331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA TAMAR PROVORNY L.C.P.C.

Provider Business Mailing Address
First Line	:	3320 W FOSTER AVE # 124
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4813
Country	:	US
Telephone Number	:	773-645-1443
Fax Number	:

Provider Business Practice Location Address
First Line	:	3320 W FOSTER AVE # 124
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60625-4813
Country	:	US
Telephone Number	:	773-645-1443
Fax Number	:

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

Provider Enumeration Date	:	04/20/2015
Last Update Date	:	05/20/2022

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