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General NPI Number Information
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NPI Number | 1215143789
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Entity Type | Organization
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Legal Business Name | GROVE AVENUE PROFESSIONAL ASSOCIATES, INC.
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 505 LIBBIE AVE
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City | RICHMOND
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State | VA
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Zip | 23226-2617
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Country | US
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Telephone | 804-288-8823
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Fax | 804-288-6423
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Provider Business Mailing Address
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Address Line | 505 LIBBIE AVE
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City | RICHMOND
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State | VA
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Zip | 23226-2617
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Country | US
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Telephone | 804-288-8823
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LESLIE ELLIS MONTGOMERY
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Credential | PH.D.
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Telephone | 804-288-8823
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810000730
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License Number State | VA
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