Provider Demographics
NPI:1003011321
Name:BARKSTALL, LISA DIANE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DIANE
Last Name:BARKSTALL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 ARLINGTON CT
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-5002
Mailing Address - Country:US
Mailing Address - Phone:773-703-3583
Mailing Address - Fax:
Practice Address - Street 1:1801 FOX DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7236
Practice Address - Country:US
Practice Address - Phone:217-398-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0050511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical