Provider Demographics
NPI:1205326303
Name:INSIDEOUT LIVING INC II
Entity type:Organization
Organization Name:INSIDEOUT LIVING INC II
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ENGAGEMENT OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LCPC,CSAT,CMAT
Authorized Official - Phone:847-328-7588
Mailing Address - Street 1:1618 ORRINGTON AVE STE 311
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-5016
Mailing Address - Country:US
Mailing Address - Phone:847-868-6783
Mailing Address - Fax:
Practice Address - Street 1:1618 ORRINGTON AVE STE 311
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-5016
Practice Address - Country:US
Practice Address - Phone:847-868-6783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-007-044101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty