Provider Demographics
NPI:1013091982
Name:STORY, LISA B (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:B
Last Name:STORY
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 1:4343 SHALLOWFORD RD
Mailing Address - Street 2:SUITE E1
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5023
Mailing Address - Country:US
Mailing Address - Phone:678-237-1827
Mailing Address - Fax:678-868-1808
Practice Address - Street 1:4343 SHALLOWFORD RD
Practice Address - Street 2:SUITE E1
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5023
Practice Address - Country:US
Practice Address - Phone:678-237-1827
Practice Address - Fax:678-868-1808
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3178103TC0700X
OR2126103TC0700X
GAPSY003714103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare ID - Type Unspecified
NC2822848Medicare ID - Type Unspecified