Provider Demographics
NPI:1194069153
Name:BRASCH, LISA (LCSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRASCH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 W GRANVILLE AVE APT 909
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-5208
Mailing Address - Country:US
Mailing Address - Phone:773-554-1710
Mailing Address - Fax:
Practice Address - Street 1:4085 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2117
Practice Address - Country:US
Practice Address - Phone:773-883-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149007659101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health