Provider Demographics
NPI:1700301058
Name:CHILDERS, LISA GAIL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:GAIL
Last Name:CHILDERS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 W TIMBER RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2057
Mailing Address - Country:US
Mailing Address - Phone:309-251-9967
Mailing Address - Fax:
Practice Address - Street 1:508 W TIMBER RIDGE DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-2057
Practice Address - Country:US
Practice Address - Phone:309-251-9967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490152651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical