Provider Demographics
NPI:1831268069
Name:LI, BETH GRUBB (LAC)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:GRUBB
Last Name:LI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12012 ASHLEY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2336
Mailing Address - Country:US
Mailing Address - Phone:410-591-2644
Mailing Address - Fax:
Practice Address - Street 1:410 MAIN ST
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-1906
Practice Address - Country:US
Practice Address - Phone:410-591-2644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU01365171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD25CVBROtherBCBSCAREFIRST MD PROVIDER
DC6310OtherBCBSCAREFIRST DC PROVIDER