Provider Demographics
NPI:1457612400
Name:GROSSMAN, LEAH
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:GROSSMAN
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 1:10 MONTGOMERY AVE
Mailing Address - Street 2:APTARTMENT A2
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2949
Mailing Address - Country:US
Mailing Address - Phone:248-281-5476
Mailing Address - Fax:
Practice Address - Street 1:10 MONTGOMERY AVE
Practice Address - Street 2:APTARTMENT A2
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-2949
Practice Address - Country:US
Practice Address - Phone:248-281-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC012308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist