Healthcare Provider Details

I. General information

NPI: 1144525692
Provider Name (Legal Business Name): MRS. LISA GALE GRESHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 N SPRING ST
HARRISON AR
72601-2913
US

IV. Provider business mailing address

PO BOX 2578
BATESVILLE AR
72503-2578
US

V. Phone/Fax

Practice location:
  • Phone: 866-308-9925
  • Fax: 870-741-4784
Mailing address:
  • Phone: 870-793-8900
  • Fax: 870-793-8959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: