Provider Demographics
NPI:1114019759
Name:GRUNBLATT, ELLEN MIRIAM (MD, LCPC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:MIRIAM
Last Name:GRUNBLATT
Suffix:
Gender:F
Credentials:MD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:672 WILTON RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6138
Mailing Address - Country:US
Mailing Address - Phone:207-778-5792
Mailing Address - Fax:
Practice Address - Street 1:672 WILTON RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938-6138
Practice Address - Country:US
Practice Address - Phone:207-778-5792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional