Provider Demographics
NPI:1215143789
Name:GROVE AVENUE PROFESSIONAL ASSOCIATES, INC.
Entity type:Organization
Organization Name:GROVE AVENUE PROFESSIONAL ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:804-288-8823
Mailing Address - Street 1:505 LIBBIE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-2617
Mailing Address - Country:US
Mailing Address - Phone:804-288-8823
Mailing Address - Fax:
Practice Address - Street 1:505 LIBBIE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-2617
Practice Address - Country:US
Practice Address - Phone:804-288-8823
Practice Address - Fax:804-288-6423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000730103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty