Provider Demographics
NPI:1932417201
Name:DWORKIN, LISA K (BCBA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:DWORKIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34061 N OLD WALNUT CIR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-4263
Mailing Address - Country:US
Mailing Address - Phone:847-223-4639
Mailing Address - Fax:
Practice Address - Street 1:34061 N OLD WALNUT CIR
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-4263
Practice Address - Country:US
Practice Address - Phone:847-223-4639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-20
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-10-6803103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst