Provider Demographics
NPI:1821200254
Name:CHEYETTE, LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CHEYETTE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FARM TRAK
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-4215
Mailing Address - Country:US
Mailing Address - Phone:770-594-6583
Mailing Address - Fax:
Practice Address - Street 1:1150 UPPER HEMBREE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1142
Practice Address - Country:US
Practice Address - Phone:678-624-0930
Practice Address - Fax:678-624-0730
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001881103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00637722DMedicaid
GA68BBDNDMedicare ID - Type UnspecifiedMEDICARE NUMBER