Healthcare Provider Details

I. General information

NPI: 1710014089
Provider Name (Legal Business Name): LISE GRONDAHL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR
STANFORD CA
94305-2200
US

IV. Provider business mailing address

2680 HANOVER ST
PALO ALTO CA
94304-1117
US

V. Phone/Fax

Practice location:
  • Phone: 650-498-5710
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA51187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: