Provider Demographics
NPI:1073661740
Name:GRUBB, LISA (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GRUBB
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 ALBERTI DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-5333
Mailing Address - Country:US
Mailing Address - Phone:843-621-2101
Mailing Address - Fax:843-317-9944
Practice Address - Street 1:2812 ALBERTI DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-5333
Practice Address - Country:US
Practice Address - Phone:843-621-2101
Practice Address - Fax:843-317-9944
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC804225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH0390Medicaid