Provider Demographics
NPI:1881746170
Name:RALSTON, LISA S (MS, OTR L)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:S
Last Name:RALSTON
Suffix:
Gender:F
Credentials:MS, 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:P. O. BOX 7475
Mailing Address - Street 2:3038 ST. CHARLES AVE.
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504
Mailing Address - Country:US
Mailing Address - Phone:770-654-0667
Mailing Address - Fax:770-531-9330
Practice Address - Street 1:3038 ST. CHARLES AVE.
Practice Address - Street 2:3038 ST. CHARLES AVE.
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504
Practice Address - Country:US
Practice Address - Phone:770-654-0667
Practice Address - Fax:770-531-9330
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3484225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00932764AMedicaid