Provider Demographics
NPI:1134648504
Name:LONDON, LISA MARIE (MA, LPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:LONDON
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 N MCCLURG CT UNIT 3704
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3984
Mailing Address - Country:US
Mailing Address - Phone:312-961-8090
Mailing Address - Fax:
Practice Address - Street 1:545 N MCCLURG CT UNIT 3704
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3984
Practice Address - Country:US
Practice Address - Phone:312-961-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.012779101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health