Provider Demographics
NPI:1124539069
Name:GROUBERT, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:GROUBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2107 N VERMONT AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-1930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5675 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4712
Practice Address - Country:US
Practice Address - Phone:323-965-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-18
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60549102X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA60549OtherRADT-1