Provider Demographics
NPI:1265910301
Name:ROE, LISA HARRIETT (BA MA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:HARRIETT
Last Name:ROE
Suffix:
Gender:F
Credentials:BA MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 W CHARLESTON BLVD STE 121
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-9237
Mailing Address - Country:US
Mailing Address - Phone:702-228-6215
Mailing Address - Fax:
Practice Address - Street 1:6600 W CHARLESTON BLVD STE 121
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-9237
Practice Address - Country:US
Practice Address - Phone:702-228-6215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer