Provider Demographics
NPI:1427463405
Name:LISA WALLACE
Entity type:Organization
Organization Name:LISA WALLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:708-906-0205
Mailing Address - Street 1:1835 W 34TH ST
Mailing Address - Street 2:
Mailing Address - City:STEGER
Mailing Address - State:IL
Mailing Address - Zip Code:60475-1499
Mailing Address - Country:US
Mailing Address - Phone:708-906-0205
Mailing Address - Fax:
Practice Address - Street 1:20200 GOVERNORS DR
Practice Address - Street 2:107
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1032
Practice Address - Country:US
Practice Address - Phone:708-462-4235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008731101Y00000X, 101YA0400X, 101YM0800X, 101YP1600X, 101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty