Provider Demographics
NPI:1659930436
Name:REH, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:REH
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 1:25440 S GOUGAR RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-9511
Mailing Address - Country:US
Mailing Address - Phone:815-478-4527
Mailing Address - Fax:
Practice Address - Street 1:25440 S GOUGAR RD
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-9511
Practice Address - Country:US
Practice Address - Phone:815-478-4527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1864015103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool