Provider Demographics
NPI:1205814498
Name:GRONDAHL, LISA (OTR)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRONDAHL
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 GOLDFINCH LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-6505
Mailing Address - Country:US
Mailing Address - Phone:631-692-4655
Mailing Address - Fax:631-692-4679
Practice Address - Street 1:4 GOLDFINCH LN
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-6505
Practice Address - Country:US
Practice Address - Phone:631-692-4655
Practice Address - Fax:631-692-4679
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-06
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQU1231Medicare ID - Type Unspecified