Provider Demographics
NPI:1013157510
Name:GROSSENBACHER, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GROSSENBACHER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1603 E 19TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-6563
Mailing Address - Country:US
Mailing Address - Phone:405-568-1950
Mailing Address - Fax:
Practice Address - Street 1:1603 E 19TH ST STE 105
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6563
Practice Address - Country:US
Practice Address - Phone:405-568-1950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-24
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
OK42761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200362310AMedicaid