Provider Demographics
NPI:1235861659
Name:KEARNEY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 E MAIN ST UNIT G
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2431
Mailing Address - Country:US
Mailing Address - Phone:630-880-0993
Mailing Address - Fax:
Practice Address - Street 1:1601 E MAIN ST UNIT G
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2431
Practice Address - Country:US
Practice Address - Phone:630-880-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146-001327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist