Provider Demographics
NPI:1568839314
Name:WOLFF, LARA LIESMA (LCPC)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:LIESMA
Last Name:WOLFF
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1746 W WINNEMAC AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-2747
Mailing Address - Country:US
Mailing Address - Phone:773-954-9315
Mailing Address - Fax:
Practice Address - Street 1:1507 W LAWRENCE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-4702
Practice Address - Country:US
Practice Address - Phone:773-569-1468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012328101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional