Provider Demographics
NPI:1467968735
Name:GROSVENOR, LEA RAE (LCDC III)
Entity Type:Individual
Prefix:MRS
First Name:LEA
Middle Name:RAE
Last Name:GROSVENOR
Suffix:
Gender:F
Credentials:LCDC III
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:RAE
Other - Last Name:MIDDLETON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCDC III
Mailing Address - Street 1:615 ELSINORE PL STE 300
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45202-1475
Mailing Address - Country:US
Mailing Address - Phone:513-834-7063
Mailing Address - Fax:513-873-1567
Practice Address - Street 1:5108 SANDY LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014-2738
Practice Address - Country:US
Practice Address - Phone:513-834-7063
Practice Address - Fax:513-873-1567
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLCDCIII.141046101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)