Provider Demographics
NPI:1740765429
Name:MUHAMMAD, LISA DENISE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DENISE
Last Name:MUHAMMAD
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 1:6835 S CALUMET AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-4004
Mailing Address - Country:US
Mailing Address - Phone:773-504-5481
Mailing Address - Fax:
Practice Address - Street 1:620 WING ST STE 3
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-2800
Practice Address - Country:US
Practice Address - Phone:847-450-0524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.10.293101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health