Individual
LISA TAMAR PROVORNY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
L.C.P.C.
Contact information
Practice address
3320 W FOSTER AVE # 124, CHICAGO, IL 60625-4813
(773) 645-1443
Mailing address
3320 W FOSTER AVE # 124, CHICAGO, IL 60625-4813
(773) 645-1443
Taxonomy
Speciality
Code
Description
License number
State
101Y00000X
Counselor
Primary
180011361
IL
Other
Enumeration date
04/20/2015
Last updated
05/20/2022
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