Provider Demographics
NPI:1043310675
Name:GRUBB, SUSAN L (DOM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:GRUBB
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 TRINITY DR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-4106
Mailing Address - Country:US
Mailing Address - Phone:505-661-1144
Mailing Address - Fax:
Practice Address - Street 1:1460 TRINITY DR
Practice Address - Street 2:SUITE 7
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-4106
Practice Address - Country:US
Practice Address - Phone:505-661-1144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM799171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist