Provider Demographics
NPI:1487006854
Name:RACIAK, LISA (LSW)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RACIAK
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 W WASHINGTON BLVD
Mailing Address - Street 2:SUITE 113
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-2203
Mailing Address - Country:US
Mailing Address - Phone:888-736-3611
Mailing Address - Fax:
Practice Address - Street 1:2081 CALISTOGA DR
Practice Address - Street 2:SUITE #2S
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-4831
Practice Address - Country:US
Practice Address - Phone:888-736-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150015479104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker