Provider Demographics
NPI:1548636632
Name:FRAHER, LISA MARIE (DPT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FRAHER
Suffix:
Gender:F
Credentials:DPT
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 670207
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0121
Mailing Address - Country:US
Mailing Address - Phone:770-643-0868
Mailing Address - Fax:770-643-0869
Practice Address - Street 1:2850 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5684
Practice Address - Country:US
Practice Address - Phone:770-643-0868
Practice Address - Fax:770-643-0869
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA012005225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA012005OtherPT LICENSE