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NPI Code Detail

MEDICARE: LISA R. GROSSMAN PH.D.

MEDICARE: LISA R. GROSSMAN PH.D.
Medicare Provider Information

Scope of Practice

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

# Taxonomy Code Taxonomy License Number License Number State
1103TC0700XClinical PsychologistPSY19121CA

General Provider Information

NPI Number : 1215994199
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA R. GROSSMAN PH.D.
Provider Business Mailing Address
First Line : 825 COLLEGE AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95404-4108
Country : US
Telephone Number : 707-539-1355
Fax Number : 707-539-1355
Provider Business Practice Location Address
First Line : 825 COLLEGE AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95404-4108
Country : US
Telephone Number : 707-539-1355
Fax Number : 707-539-1355
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/26/2006
Last Update Date : 07/08/2007

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