Provider Demographics
NPI:1770921181
Name:FESSETT O'LEARY, LISA ANN
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:FESSETT O'LEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:FESSETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10513 S DRAKE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60655-2503
Mailing Address - Country:US
Mailing Address - Phone:773-445-3513
Mailing Address - Fax:
Practice Address - Street 1:10513 S DRAKE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60655-2503
Practice Address - Country:US
Practice Address - Phone:773-445-3513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist