Provider Demographics
NPI:1689626541
Name:GILLIAM, LISA L (PT)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:L
Last Name:GILLIAM
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:D
Other - Last Name:LOCKETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 32709
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37930-2709
Mailing Address - Country:US
Mailing Address - Phone:865-558-6484
Mailing Address - Fax:865-584-4037
Practice Address - Street 1:8904 CROSS PARK DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4703
Practice Address - Country:US
Practice Address - Phone:865-690-2671
Practice Address - Fax:865-690-6445
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3154494OtherBLUE CROSS
TN3652046Medicaid
TNCH4394OtherMEDICARE-RAILROAD GROUP ID
TN3652046Medicare ID - Type Unspecified