Provider Demographics
NPI:1831372234
Name:LAKE, LISA RAMSLAND (OTR/L)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RAMSLAND
Last Name:LAKE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4517 CALLIE DOWNS DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5126
Mailing Address - Country:US
Mailing Address - Phone:678-943-5130
Mailing Address - Fax:770-783-6599
Practice Address - Street 1:4517 CALLIE DOWNS DRIVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-5126
Practice Address - Country:US
Practice Address - Phone:678-943-5130
Practice Address - Fax:770-783-6599
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT001143225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA419667629AMedicaid
GA419667629BMedicaid
GA419667629DMedicaid
GA419667629CMedicaid