Provider Demographics
NPI:1245648708
Name:KOHUT, LISA MICHELLE (EDD, EDS, MED,)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:KOHUT
Suffix:
Gender:F
Credentials:EDD, EDS, MED,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 JENNIFER CIR
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-4111
Mailing Address - Country:US
Mailing Address - Phone:847-845-2092
Mailing Address - Fax:
Practice Address - Street 1:800 E NORTHWEST HWY
Practice Address - Street 2:STE 106
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3457
Practice Address - Country:US
Practice Address - Phone:847-845-2092
Practice Address - Fax:847-299-4952
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-29
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
IL180.005444101YA0400X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral