Provider Demographics
NPI:1306819776
Name:KYLE-WOLF, LISA MARIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:KYLE-WOLF
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:RUTHERFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7501 N UNIVERSITY ST STE 217B
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-1252
Mailing Address - Country:US
Mailing Address - Phone:309-696-8369
Mailing Address - Fax:312-254-1423
Practice Address - Street 1:7501 N UNIVERSITY ST STE 217B
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-1252
Practice Address - Country:US
Practice Address - Phone:309-696-8369
Practice Address - Fax:312-254-1423
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490020701041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206701Medicare ID - Type Unspecified