Provider Demographics
NPI:1386991560
Name:BANNER, LISA ANN (MA)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:ANN
Last Name:BANNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 N SPRING AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-5922
Mailing Address - Country:US
Mailing Address - Phone:630-254-4805
Mailing Address - Fax:
Practice Address - Street 1:800 W 5TH AVE
Practice Address - Street 2:205I
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8965
Practice Address - Country:US
Practice Address - Phone:630-779-0751
Practice Address - Fax:630-753-0942
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1800075791101YP2500X
IL2442773101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool