Provider Demographics
NPI:1528100484
Name:BERG, LISA M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BERG
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 1:869 MOCKING BIRD DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-2726
Mailing Address - Country:US
Mailing Address - Phone:224-788-8156
Mailing Address - Fax:
Practice Address - Street 1:532 LAKE ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002-1424
Practice Address - Country:US
Practice Address - Phone:706-957-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490071421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL519320Medicare ID - Type Unspecified