Provider Demographics
NPI:1619605516
Name:GRANDPRE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRANDPRE
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 1:2905 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-5420
Mailing Address - Country:US
Mailing Address - Phone:605-626-4380
Mailing Address - Fax:605-626-4381
Practice Address - Street 1:2905 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5420
Practice Address - Country:US
Practice Address - Phone:605-626-4380
Practice Address - Fax:605-626-4381
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1940225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist