Provider Demographics
NPI:1972345312
Name:ROBERTS, LISA MICHELLE (ATC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:WILCOXSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:265 E ROLLINS ST STE 11100
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5570
Mailing Address - Country:US
Mailing Address - Phone:407-502-6919
Mailing Address - Fax:
Practice Address - Street 1:265 E ROLLINS ST STE 11100
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5570
Practice Address - Country:US
Practice Address - Phone:407-502-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-07
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL65052255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer