Provider Demographics
NPI:1619731650
Name:KERNAGHAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KERNAGHAN
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 1:1104 HUNTER ST
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-4822
Mailing Address - Country:US
Mailing Address - Phone:630-433-1804
Mailing Address - Fax:
Practice Address - Street 1:1337 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4829
Practice Address - Country:US
Practice Address - Phone:610-888-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0255101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty