Basic Information
| Provider Information | |||||||||
| NPI: | 1336255215 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAU | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 453 | ||||||||
| Address2: | |||||||||
| City: | ELMWOOD PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074070453 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4400 BISCAYNE BLVD | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8334363832 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2006 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | Y | Other Service Providers | Genetic Counselor, MS |
ID Information
| ID | Type | State | Issuer | Description | 70.000010 | 01 | OH | OHIO GENETIC COUNSELOR LICENSURE | OTHER |