Provider Demographics
NPI:1083780381
Name:HAAKE, LISA (PHD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:HAAKE
Suffix:
Gender:F
Credentials:PHD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 S SMITH RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-4750
Mailing Address - Country:US
Mailing Address - Phone:217-299-1342
Mailing Address - Fax:217-344-4733
Practice Address - Street 1:507 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61801-3108
Practice Address - Country:US
Practice Address - Phone:217-721-2617
Practice Address - Fax:217-344-4733
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01032083OtherBCBSIL PROVIDER ID