Provider Demographics
NPI:1467084897
Name:JOHNSON, LISA S
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 EXETER PL
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1521
Mailing Address - Country:US
Mailing Address - Phone:847-373-8052
Mailing Address - Fax:
Practice Address - Street 1:510 EXETER PL
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1521
Practice Address - Country:US
Practice Address - Phone:847-373-8052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator