Provider Demographics
NPI:1528467503
Name:PETERSON, LISA (LMFT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 W BERTEAU AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-6131
Mailing Address - Country:US
Mailing Address - Phone:312-278-3771
Mailing Address - Fax:
Practice Address - Street 1:1770 W BERTEAU AVE STE 304
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-6131
Practice Address - Country:US
Practice Address - Phone:312-278-3771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166001244106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist