Healthcare Provider Details

I. General information

NPI: 1881873495
Provider Name (Legal Business Name): LISA GRAY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3001 HIGHLAND AVE SUITE A
CINCINNATI OH
45219-2315
US

IV. Provider business mailing address

3001 HIGHLAND AVE SUITE A
CINCINNATI OH
45219-2315
US

V. Phone/Fax

Practice location:
  • Phone: 513-961-8484
  • Fax: 513-487-2315
Mailing address:
  • Phone: 513-961-8484
  • Fax: 513-487-2315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number35.094685
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35.094685
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: