Provider Demographics
NPI:1730066556
Name:LANDIS, LISA (PTA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LANDIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 LAFAYETTE DR SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-5537
Mailing Address - Country:US
Mailing Address - Phone:912-293-7056
Mailing Address - Fax:
Practice Address - Street 1:9390 THE LANDING DR # 201
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7180
Practice Address - Country:US
Practice Address - Phone:770-852-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003940225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant