Provider Demographics
NPI:1154818094
Name:GRUNT, THEODORE
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:GRUNT
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 1:172 KINGSTON AVE APT C
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2323
Mailing Address - Country:US
Mailing Address - Phone:805-967-3207
Mailing Address - Fax:
Practice Address - Street 1:4444 CALLE REAL
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110-1002
Practice Address - Country:US
Practice Address - Phone:805-681-5220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator