Provider Demographics
NPI:1609170588
Name:PARKS-JOHNSON, LISA (PSYD, LCPC, CADC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PARKS-JOHNSON
Suffix:
Gender:F
Credentials:PSYD, LCPC, CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22923 MILLARD AVE
Mailing Address - Street 2:
Mailing Address - City:RICHTON PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60471-2534
Mailing Address - Country:US
Mailing Address - Phone:708-302-1253
Mailing Address - Fax:
Practice Address - Street 1:22923 MILLARD AVE
Practice Address - Street 2:
Practice Address - City:RICHTON PARK
Practice Address - State:IL
Practice Address - Zip Code:60471-2534
Practice Address - Country:US
Practice Address - Phone:708-302-1253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180002716101YP2500X
IL21715101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)