Provider Demographics
NPI:1518965730
Name:OGLESBY, LISA LILLARD (PT, PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LILLARD
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:PT, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N NORTHSHORE DR STE S490
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-2808
Mailing Address - Country:US
Mailing Address - Phone:865-584-0171
Mailing Address - Fax:865-584-0174
Practice Address - Street 1:1111 N NORTHSHORE DR STE S490
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-2808
Practice Address - Country:US
Practice Address - Phone:865-584-0171
Practice Address - Fax:865-584-0174
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPT764225100000X
TNP2740103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3646591Medicaid
TN36465911Medicaid
TN36465911Medicaid
TN3646591Medicaid