Provider Demographics
NPI:1235343583
Name:GRUMBLES, THERESA VILA (MA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:VILA
Last Name:GRUMBLES
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4182 N BANK ST
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-2715
Mailing Address - Country:US
Mailing Address - Phone:928-692-6456
Mailing Address - Fax:928-692-1507
Practice Address - Street 1:4182 N BANK ST
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-2715
Practice Address - Country:US
Practice Address - Phone:928-692-6456
Practice Address - Fax:928-692-1507
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ567729Medicaid