MEDICARE: ALISA GROVE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YP2500X	Professional Counselor
2	102L00000X	Psychoanalyst
3	106H00000X	Marriage & Family Therapist
4	101Y00000X	Counselor
5	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124635081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALISA GROVE PA

Provider Business Mailing Address
First Line	:	4408 BEDFORD WAY
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-1321
Country	:	US
Telephone Number	:	407-421-2031
Fax Number	:	407-604-6497

Provider Business Practice Location Address
First Line	:	4408 BEDFORD WAY
Second Line	:
City	:	LEESBURG
State	:	FL
Zip	:	34748-1321
Country	:	US
Telephone Number	:	407-421-2031
Fax Number	:	407-604-6497

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	ALISA GROVE
Credential	:	LMHC
Telephone Number	:	407-421-2031

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	05/30/2024

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Directions to “ALISA GROVE PA ” Practice Location

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