Provider Demographics
NPI:1215297254
Name:LAMBETH, LISA SHAW (OTAL)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SHAW
Last Name:LAMBETH
Suffix:
Gender:F
Credentials:OTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 COBLE AVE
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-5511
Mailing Address - Country:US
Mailing Address - Phone:704-322-5569
Mailing Address - Fax:
Practice Address - Street 1:611 COBLE AVE
Practice Address - Street 2:
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-5511
Practice Address - Country:US
Practice Address - Phone:704-322-5569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC644224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant