Provider Demographics
NPI:1609175744
Name:MEDALIE, LISA (PSYD, CBSM)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MEDALIE
Suffix:
Gender:F
Credentials:PSYD, CBSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 DAVIS ST STE 5767
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5945
Mailing Address - Country:US
Mailing Address - Phone:844-475-3379
Mailing Address - Fax:855-644-2981
Practice Address - Street 1:1101 DAVIS ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5945
Practice Address - Country:US
Practice Address - Phone:773-702-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-15
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.008089103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist