Provider Demographics
NPI:1487874764
Name:GRUVER, LISA SQUIERS
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:SQUIERS
Last Name:GRUVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6453 NW 21ST CT
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-2211
Mailing Address - Country:US
Mailing Address - Phone:786-877-0616
Mailing Address - Fax:
Practice Address - Street 1:6453 NW 21ST CT
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-2211
Practice Address - Country:US
Practice Address - Phone:786-877-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT21919225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891615200Medicaid