Provider Demographics
NPI:1699375592
Name:LISSUZZO, ANDREA DOHERTY (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:DOHERTY
Last Name:LISSUZZO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:DOHERTY
Other - Last Name:LISSUZZO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:526 KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1612
Mailing Address - Country:US
Mailing Address - Phone:708-710-2650
Mailing Address - Fax:
Practice Address - Street 1:526 KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1612
Practice Address - Country:US
Practice Address - Phone:708-710-2650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0074671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical