Provider Demographics
NPI:1063099695
Name:BROWN, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1461 W 112TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4368
Mailing Address - Country:US
Mailing Address - Phone:619-772-0297
Mailing Address - Fax:
Practice Address - Street 1:1461 W 112TH PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-4368
Practice Address - Country:US
Practice Address - Phone:312-646-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
IL180.016145101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional