Basic Information
| Provider Information | |||||||||
| NPI: | 1003011321 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARKSTALL | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 ARLINGTON CT | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618205002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7737033583 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1801 FOX DR | ||||||||
| Address2: | |||||||||
| City: | CHAMPAIGN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618207236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173988080 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 04/08/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.005051 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.