Provider Demographics
NPI:1023250388
Name:DAVIS, LISSA LOWRY (PHD)
Entity type:Individual
Prefix:DR
First Name:LISSA
Middle Name:LOWRY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LISSA
Other - Middle Name:
Other - Last Name:TCHERNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:108 E PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2512
Mailing Address - Country:US
Mailing Address - Phone:678-952-7078
Mailing Address - Fax:
Practice Address - Street 1:108 E PONCE DE LEON AVE
Practice Address - Street 2:208
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2512
Practice Address - Country:US
Practice Address - Phone:678-952-7078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003404103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical