Provider Demographics
NPI:1760378723
Name:WALSH, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WALSH
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 1:1044 EVERGREEN ST
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1262
Mailing Address - Country:US
Mailing Address - Phone:815-260-3137
Mailing Address - Fax:
Practice Address - Street 1:1850 W WINCHESTER RD STE 108
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5355
Practice Address - Country:US
Practice Address - Phone:224-424-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.008770101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional