Provider Demographics
NPI:1275969933
Name:JUSTICE, LISA JO
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JO
Last Name:JUSTICE
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 1:1149 SUNSHINE LN
Mailing Address - Street 2:
Mailing Address - City:KIMPER
Mailing Address - State:KY
Mailing Address - Zip Code:41539-6455
Mailing Address - Country:US
Mailing Address - Phone:606-631-6564
Mailing Address - Fax:
Practice Address - Street 1:1149 SUNSHINE LN
Practice Address - Street 2:
Practice Address - City:KIMPER
Practice Address - State:KY
Practice Address - Zip Code:41539-6455
Practice Address - Country:US
Practice Address - Phone:606-631-6564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY200002555222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist