Provider Demographics
NPI:1770746778
Name:SWANK, LISA MARIE (MA, LCPC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:SWANK
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7626
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61126-7626
Mailing Address - Country:US
Mailing Address - Phone:815-540-4308
Mailing Address - Fax:
Practice Address - Street 1:5950 SPRING CREEK ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61126
Practice Address - Country:US
Practice Address - Phone:815-540-4308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006630101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional