Provider Demographics
NPI:1417375650
Name:JOHNSON, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:JOHNSON
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 1:602 GROVE ST
Mailing Address - Street 2:
Mailing Address - City:HENRY
Mailing Address - State:IL
Mailing Address - Zip Code:61537-1204
Mailing Address - Country:US
Mailing Address - Phone:309-714-0354
Mailing Address - Fax:
Practice Address - Street 1:28 E MARION ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:IL
Practice Address - Zip Code:61356-2093
Practice Address - Country:US
Practice Address - Phone:815-875-2192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2021-03-25
Deactivation Date:2021-03-02
Deactivation Code:
Reactivation Date:2021-03-25
Provider Licenses
StateLicense IDTaxonomies
IL149.0113721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical