Provider Demographics
NPI:1194799312
Name:MEDANIC, LISA C (LCPC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:MEDANIC
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 CRYSTAL ROCK RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8241
Mailing Address - Country:US
Mailing Address - Phone:630-904-9230
Mailing Address - Fax:630-904-9871
Practice Address - Street 1:29W120 BUTTERFIELD RD STE 104A
Practice Address - Street 2:
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-2830
Practice Address - Country:US
Practice Address - Phone:630-393-4019
Practice Address - Fax:630-904-9871
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional