Provider Demographics
NPI:1124410675
Name:WIESE, LISA JANE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:WIESE
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 1:2020 N MOZART ST APT 221
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3977
Mailing Address - Country:US
Mailing Address - Phone:773-632-8675
Mailing Address - Fax:
Practice Address - Street 1:2950 W CHICAGO AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-4375
Practice Address - Country:US
Practice Address - Phone:773-632-8675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490149771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical