Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 149015331 | IL |
NPI | 1003242124 |
---|---|
Provider Name | Ms. Lisa Raubolt |
First Address | Chicago, IL 60611-2927 |
Second Address | Chicago, IL 60611-2927 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2013 |
Last Update Date | 02/02/2015 |