Provider Demographics
NPI:1932477866
Name:STEPHEN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STEPHEN
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 1:7144 S PAULINA ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60636-3823
Mailing Address - Country:US
Mailing Address - Phone:773-776-8759
Mailing Address - Fax:
Practice Address - Street 1:4735 WILLOW SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-6130
Practice Address - Country:US
Practice Address - Phone:708-698-5259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-07
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.009515225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist