Provider Demographics
NPI:1144318486
Name:FOWLER, LISA JABLON (LCPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:JABLON
Last Name:FOWLER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 OLD GLENVIEW RD
Mailing Address - Street 2:#3
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2963
Mailing Address - Country:US
Mailing Address - Phone:847-612-1423
Mailing Address - Fax:
Practice Address - Street 1:3330 OLD GLENVIEW RD
Practice Address - Street 2:#3
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2963
Practice Address - Country:US
Practice Address - Phone:847-612-1423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-004739101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health