Provider Demographics
NPI:1306487798
Name:KUSUMPA, LISA (MSW, LCSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:KUSUMPA
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5017 W BERTEAU AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-1738
Mailing Address - Country:US
Mailing Address - Phone:773-490-6486
Mailing Address - Fax:
Practice Address - Street 1:204 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005-1646
Practice Address - Country:US
Practice Address - Phone:773-490-6486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-07
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490109091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical