Provider Demographics
NPI:1447874243
Name:GABRIELSON, LISA (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GABRIELSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4421 FALLOWFIELD LN SW
Mailing Address - Street 2:
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-7403
Mailing Address - Country:US
Mailing Address - Phone:770-979-4926
Mailing Address - Fax:
Practice Address - Street 1:20 GRAYSON NEW HOPE RD STE C
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-4316
Practice Address - Country:US
Practice Address - Phone:770-682-3854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004025225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist