Healthcare Provider Details

I. General information

NPI: 1164628152
Provider Name (Legal Business Name): LISA HELMS SHAW P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 03/27/2020
Certification Date: 03/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 LANTERN COACH LN NE
ROSWELL GA
30075-3195
US

IV. Provider business mailing address

3302 LANTERN COACH LN NE
ROSWELL GA
30075-3195
US

V. Phone/Fax

Practice location:
  • Phone: 404-210-2093
  • Fax:
Mailing address:
  • Phone: 404-210-2093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License NumberPT006128
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT006128
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT006128
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: