Provider Demographics
NPI:1154489516
Name:WADE, LISA GAY (OTRL)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GAY
Last Name:WADE
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:GAY
Other - Last Name:SKEEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTRL
Mailing Address - Street 1:557 GLOVER AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2070
Mailing Address - Country:US
Mailing Address - Phone:334-347-0234
Mailing Address - Fax:334-393-4495
Practice Address - Street 1:557 GLOVER AVE STE 5
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2070
Practice Address - Country:US
Practice Address - Phone:334-347-0234
Practice Address - Fax:334-393-4495
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0106174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist