Provider Demographics
NPI:1801290622
Name:GREY, LISA L (LCAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:GREY
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 106
Mailing Address - Street 2:
Mailing Address - City:LEBO
Mailing Address - State:KS
Mailing Address - Zip Code:66856-0106
Mailing Address - Country:US
Mailing Address - Phone:620-757-1059
Mailing Address - Fax:620-256-9000
Practice Address - Street 1:2611 FAUNA RD
Practice Address - Street 2:
Practice Address - City:LEBO
Practice Address - State:KS
Practice Address - Zip Code:66856
Practice Address - Country:US
Practice Address - Phone:620-757-1059
Practice Address - Fax:620-256-9000
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-22
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS605101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS12691970OtherCAQH