Provider Demographics
NPI:1124635081
Name:ALISA GROVE PA
Entity type:Organization
Organization Name:ALISA GROVE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-421-2031
Mailing Address - Street 1:4408 BEDFORD WAY
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-1321
Mailing Address - Country:US
Mailing Address - Phone:407-421-2031
Mailing Address - Fax:407-604-6497
Practice Address - Street 1:4408 BEDFORD WAY
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-1321
Practice Address - Country:US
Practice Address - Phone:407-421-2031
Practice Address - Fax:407-604-6497
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALISA GROVE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-24
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalystGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122073300Medicaid