Provider Demographics
NPI:1467745612
Name:GRUNDY, LISA (MA, QMHP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:GRUNDY
Suffix:
Gender:F
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10313 SW 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-9103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11895 SW GREENBURG RD
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-6450
Practice Address - Country:US
Practice Address - Phone:503-726-3690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health