Healthcare Provider Details

I. General information

NPI: 1912042219
Provider Name (Legal Business Name): LISA LUISE HEUSEL-GILLIG MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 CLIFTON RD NE
ATLANTA GA
30322-1004
US

IV. Provider business mailing address

151 COVENTRY RD
DECATUR GA
30030-2302
US

V. Phone/Fax

Practice location:
  • Phone: 404-712-4803
  • Fax:
Mailing address:
  • Phone: 404-377-6164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number002203
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: