Provider Demographics
NPI:1063974095
Name:JOHNSON, IMANI LISA (LCSW)
Entity type:Individual
Prefix:
First Name:IMANI
Middle Name:LISA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:IMANI
Other - Middle Name:LISA
Other - Last Name:CHEESEBOUROUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:20821 GREENWOOD CENTER CT
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1354
Mailing Address - Country:US
Mailing Address - Phone:708-275-3419
Mailing Address - Fax:
Practice Address - Street 1:8053 KOLMAR AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-3114
Practice Address - Country:US
Practice Address - Phone:847-909-9858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0151971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1174821946Medicaid