Provider Demographics
NPI:1205213485
Name:LISA R GROSSMAN PHD PSYCHOLOGIST A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LISA R GROSSMAN PHD PSYCHOLOGIST A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:R
Authorized Official - Last Name:GROSSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:707-527-0295
Mailing Address - Street 1:825 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95404-4108
Mailing Address - Country:US
Mailing Address - Phone:707-527-0295
Mailing Address - Fax:707-527-4036
Practice Address - Street 1:825 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-4108
Practice Address - Country:US
Practice Address - Phone:707-527-0295
Practice Address - Fax:707-527-4036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY19121103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty