Provider Demographics
NPI:1346323730
Name:CALLOWAY, LISA MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:CALLOWAY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 428247
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-8247
Mailing Address - Country:US
Mailing Address - Phone:630-272-6240
Mailing Address - Fax:630-364-2555
Practice Address - Street 1:101 ROYCE RD
Practice Address - Street 2:SUITE 12
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1458
Practice Address - Country:US
Practice Address - Phone:630-272-6240
Practice Address - Fax:630-364-2555
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL311641OtherGROUP # FOR MHN
IL409970/57007900OtherPROVIDER # FOR MAGELLAN
IL449000OtherPROVIDER # FOR PSYCHEALTH
IL293092OtherINDIVIDUAL # FOR MHN
IL0001633386OtherBCBS PROVIDER NUMBER
IL293092OtherINDIVIDUAL # FOR MHN
ILK26577Medicare ID - Type UnspecifiedMEMBER # FOR PROVIDER