Provider Demographics
NPI:1023419348
Name:CONWAY, LISA ANNETTE (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNETTE
Last Name:CONWAY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNETTE
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:4256 N RAVENSWOOD AVE STE 215
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-1114
Mailing Address - Country:US
Mailing Address - Phone:312-471-3910
Mailing Address - Fax:
Practice Address - Street 1:4256 N RAVENSWOOD AVE STE 215
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-1114
Practice Address - Country:US
Practice Address - Phone:312-471-3910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-05
Last Update Date:2020-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071008678103TC0700X
IL071.008678103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical