Provider Demographics
NPI:1013995414
Name:LISENBY, ANGELA PORTER
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:PORTER
Last Name:LISENBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WHITE OAK TRL
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-8782
Mailing Address - Country:US
Mailing Address - Phone:404-358-8461
Mailing Address - Fax:
Practice Address - Street 1:34 WHITE OAK TRL
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-8782
Practice Address - Country:US
Practice Address - Phone:404-358-8461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004231225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA641695989AMedicaid
GA127157301AMedicaid
GA814307358AMedicaid
GA814307358BMedicaid