Provider Demographics
NPI:1831621010
Name:WADE, LISA (MS, OTR/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 CREEK LANDING LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-7813
Mailing Address - Country:US
Mailing Address - Phone:678-923-1585
Mailing Address - Fax:
Practice Address - Street 1:530 CREEK LANDING LN
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-7813
Practice Address - Country:US
Practice Address - Phone:678-923-1585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT006711225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist