Provider Demographics
NPI:1801130257
Name:HAMBRICK, LISLE
Entity type:Individual
Prefix:MS
First Name:LISLE
Middle Name:
Last Name:HAMBRICK
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 1:3407 HILL POND DR
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7329
Mailing Address - Country:US
Mailing Address - Phone:678-714-8981
Mailing Address - Fax:
Practice Address - Street 1:3100 CLUB DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2591
Practice Address - Country:US
Practice Address - Phone:770-923-3100
Practice Address - Fax:770-923-1227
Is Sole Proprietor?:No
Enumeration Date:2012-11-23
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT003350225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist