Provider Demographics
NPI:1205044534
Name:BIRDOES, LISA MARIE (LCPC)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:BIRDOES
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4617 N PROSPECT RD
Mailing Address - Street 2:SUITE 26
Mailing Address - City:PEORIA HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:61616-6450
Mailing Address - Country:US
Mailing Address - Phone:309-682-1992
Mailing Address - Fax:
Practice Address - Street 1:4617 N PROSPECT RD
Practice Address - Street 2:SUITE 26
Practice Address - City:PEORIA HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:61616-6450
Practice Address - Country:US
Practice Address - Phone:309-682-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional