Provider Demographics
NPI:1154672855
Name:GROVES, LISA MARIE (MS, ED)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:GROVES
Suffix:
Gender:F
Credentials:MS, ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 WASHINGTON AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-5504
Mailing Address - Country:US
Mailing Address - Phone:518-456-4466
Mailing Address - Fax:
Practice Address - Street 1:251 WASHINGTON AVENUE EXT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-5504
Practice Address - Country:US
Practice Address - Phone:518-456-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8106174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8106OtherSPECIALIST