Provider Demographics
NPI:1700359023
Name:CHAMPOIR-LAIRD, LISA RAE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:CHAMPOIR-LAIRD
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 1:8392 ACADIA ST NW
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-1406
Mailing Address - Country:US
Mailing Address - Phone:330-904-0368
Mailing Address - Fax:
Practice Address - Street 1:3537 12TH ST NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-3818
Practice Address - Country:US
Practice Address - Phone:330-455-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH01142225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant