Provider Demographics
NPI:1265460133
Name:MCCLURE, LISA L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 N STATE ROUTE 91
Mailing Address - Street 2:SUITE 240
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-9541
Mailing Address - Country:US
Mailing Address - Phone:309-683-5006
Mailing Address - Fax:309-683-5095
Practice Address - Street 1:8600 N STATE ROUTE 91
Practice Address - Street 2:SUITE 240
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-9541
Practice Address - Country:US
Practice Address - Phone:309-683-5006
Practice Address - Fax:309-683-5095
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071-006198103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL079195OtherHEALTH ALLIANCE
K46144Medicare PIN