Provider Demographics
NPI:1578590311
Name:STEVENS, LISA H (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:H
Last Name:STEVENS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2310 COLEY FARM RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY FACE
Mailing Address - State:GA
Mailing Address - Zip Code:30740-9734
Mailing Address - Country:US
Mailing Address - Phone:706-673-6151
Mailing Address - Fax:
Practice Address - Street 1:405 S THORNTON AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-8285
Practice Address - Country:US
Practice Address - Phone:706-226-1146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0402482084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00665871DMedicaid