Provider Demographics
NPI:1215007901
Name:GRUMM, TISA (LCSW)
Entity Type:Individual
Prefix:
First Name:TISA
Middle Name:
Last Name:GRUMM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TISA
Other - Middle Name:
Other - Last Name:JEROME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40950 CHAPEL WAY
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4236
Mailing Address - Country:US
Mailing Address - Phone:510-432-7516
Mailing Address - Fax:510-226-6352
Practice Address - Street 1:40950 CHAPEL WAY
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-4236
Practice Address - Country:US
Practice Address - Phone:510-432-7516
Practice Address - Fax:510-226-6352
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA202831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical