Provider Demographics
NPI:1588976971
Name:DEVORE, LISA M (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DEVORE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15720 BRIXHAM HILL AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4784
Mailing Address - Country:US
Mailing Address - Phone:704-412-8360
Mailing Address - Fax:704-603-3006
Practice Address - Street 1:15720 BRIXHAM HILL AVE STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-4784
Practice Address - Country:US
Practice Address - Phone:704-412-8360
Practice Address - Fax:704-603-3006
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1829103T00000X
NC4386103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ52838F600Medicare UPIN