Provider Demographics
NPI:1326590977
Name:GREY, LISANNE
Entity Type:Individual
Prefix:
First Name:LISANNE
Middle Name:
Last Name:GREY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 INLAND EMPIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4898
Mailing Address - Country:US
Mailing Address - Phone:909-732-6932
Mailing Address - Fax:909-944-1059
Practice Address - Street 1:2940 INLAND EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4898
Practice Address - Country:US
Practice Address - Phone:909-458-1376
Practice Address - Fax:909-944-1059
Is Sole Proprietor?:No
Enumeration Date:2016-10-31
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
CA9795101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other