Provider Demographics
NPI:1013129733
Name:BRENNAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRENNAN
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 1:4507 N RICHMOND ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3825
Mailing Address - Country:US
Mailing Address - Phone:773-551-8106
Mailing Address - Fax:866-672-5645
Practice Address - Street 1:4507 N RICHMOND ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3825
Practice Address - Country:US
Practice Address - Phone:773-551-8106
Practice Address - Fax:866-672-5645
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
IL178.004881101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor