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General NPI Number Information
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NPI Number | 1891565453
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Entity Type | Individual
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Provider Name | LISA JO GRANT PSY. D.
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Gender | Female
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Dates
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Enumeration Date | 01/04/2024
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Last Update Date | 01/04/2024
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Provider Practice Location Address
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Address Line | 438 CAMINO DEL RIO S STE 106
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City | SAN DIEGO
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State | CA
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Zip | 92108-3546
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Country | US
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Telephone | 855-550-6463
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Fax |
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Provider Business Mailing Address
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Address Line | 20001 OAKWOOD DR
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City | ABINGDON
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State | VA
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Zip | 24211-6915
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Country | US
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Telephone | 276-608-3528
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 0704016502
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License Number State | VA
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