Provider Demographics
NPI:1912045758
Name:GROGG, LAURIEG LEE III
Entity Type:Individual
Prefix:
First Name:LAURIEG
Middle Name:LEE
Last Name:GROGG
Suffix:III
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 1:3008 WOLF CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95423-9565
Mailing Address - Country:US
Mailing Address - Phone:707-998-1925
Mailing Address - Fax:707-994-7096
Practice Address - Street 1:991 PARALLEL DR
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453
Practice Address - Country:US
Practice Address - Phone:707-994-7090
Practice Address - Fax:707-994-7096
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health