Healthcare Provider Details

I. General information

NPI: 1396881744
Provider Name (Legal Business Name): EMILY CROCKER LISI MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 N DECATUR RD
DECATUR GA
30033-5307
US

IV. Provider business mailing address

862 HERITAGE TWO
DECATUR GA
30033-4103
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-8536
  • Fax: 404-778-8562
Mailing address:
  • Phone: 443-801-7053
  • Fax: 404-778-8562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: