Provider Demographics
NPI:1598535106
Name:MACIAS, LISA (MSW, LSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MACIAS
Suffix:
Gender:F
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5608 S MOZART ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60629-2119
Mailing Address - Country:US
Mailing Address - Phone:630-402-1605
Mailing Address - Fax:
Practice Address - Street 1:4311 N RAVENSWOOD AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1192
Practice Address - Country:US
Practice Address - Phone:847-865-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.112001101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health