Provider Demographics
NPI:1508613290
Name:HINES, LISA (PHD, LCSW, LPHA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HINES
Suffix:
Gender:F
Credentials:PHD, LCSW, LPHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17114 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429-1023
Mailing Address - Country:US
Mailing Address - Phone:415-606-7426
Mailing Address - Fax:
Practice Address - Street 1:17114 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1023
Practice Address - Country:US
Practice Address - Phone:415-606-7426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0284881041C0700X
IL150.113114104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker