Provider Demographics
NPI:1700327293
Name:GRIZZLE, LISA (COTA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRIZZLE
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 S LAVACA
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:TX
Mailing Address - Zip Code:77975-4854
Mailing Address - Country:US
Mailing Address - Phone:361-772-8419
Mailing Address - Fax:
Practice Address - Street 1:330 EL CERRO MISSION
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031
Practice Address - Country:US
Practice Address - Phone:361-772-8419
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3672171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor