Provider Demographics
NPI:1073159638
Name:BLY, LISHA
Entity Type:Individual
Prefix:
First Name:LISHA
Middle Name:
Last Name:BLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31059-0743
Mailing Address - Country:US
Mailing Address - Phone:404-884-1907
Mailing Address - Fax:
Practice Address - Street 1:2938 HERITAGE PL NE
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-7202
Practice Address - Country:US
Practice Address - Phone:404-884-1907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management