Provider Demographics
NPI:1902966799
Name:ROLES, LISA R (PTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:ROLES
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1324
Mailing Address - Street 2:
Mailing Address - City:SOPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:25921-1324
Mailing Address - Country:US
Mailing Address - Phone:304-683-9741
Mailing Address - Fax:
Practice Address - Street 1:3875 ROBERT C BYRD DR
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-253-1960
Practice Address - Fax:304-253-3080
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001053174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist