Provider Demographics
NPI:1417927344
Name:NAGATOMO-TIMMS, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:NAGATOMO-TIMMS
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 1:2800 N SHERIDAN RD
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6156
Mailing Address - Country:US
Mailing Address - Phone:773-404-0160
Mailing Address - Fax:773-404-9876
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 502
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-404-0160
Practice Address - Fax:773-404-9876
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-09-02
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
IL583330Medicare PIN