Provider Demographics
NPI:1194838268
Name:STANFORD, LISA D (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:D
Last Name:STANFORD
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2033 MILWAUKEE AVE
Mailing Address - Street 2:STE 334
Mailing Address - City:RIVERWOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60015-3581
Mailing Address - Country:US
Mailing Address - Phone:800-564-0863
Mailing Address - Fax:847-383-4380
Practice Address - Street 1:2033 MILWAUKEE AVE
Practice Address - Street 2:STE 334
Practice Address - City:RIVERWOODS
Practice Address - State:IL
Practice Address - Zip Code:60015-3581
Practice Address - Country:US
Practice Address - Phone:800-564-0863
Practice Address - Fax:847-383-4380
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006582103G00000X, 103T00000X, 103TC0700X, 103TS0200X
OH6797103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool