Provider Demographics
NPI:1073093860
Name:GRUBER, CHARLOTTE (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:GRUBER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4225 ARCADY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-3701
Mailing Address - Country:US
Mailing Address - Phone:469-955-5125
Mailing Address - Fax:
Practice Address - Street 1:5215 NORTH O'CONNOR BOULEVARD
Practice Address - Street 2:1100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039
Practice Address - Country:US
Practice Address - Phone:469-928-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX614941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid