Provider Demographics
NPI:1184267478
Name:LIGHT ON ANXIETY
Entity type:Organization
Organization Name:LIGHT ON ANXIETY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KISSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:312-508-3645
Mailing Address - Street 1:100 SAUNDERS RD STE 150
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-2526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3330 OLD GLENVIEW RD STE 14
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2963
Practice Address - Country:US
Practice Address - Phone:312-508-3645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-19
Last Update Date:2019-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL150.104002OtherLICENSED SOCIAL WORKER