Provider Demographics
NPI:1316588122
Name:GRUBBS, LEILA RENEE (MSW, LMSW)
Entity Type:Individual
Prefix:MS
First Name:LEILA
Middle Name:RENEE
Last Name:GRUBBS
Suffix:
Gender:F
Credentials:MSW, LMSW
Other - Prefix:
Other - First Name:LEILA
Other - Middle Name:RENEE
Other - Last Name:RIDDICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW, LMSW
Mailing Address - Street 1:140 CHANCELLOR AVE APT B1
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07112-1985
Mailing Address - Country:US
Mailing Address - Phone:929-235-0230
Mailing Address - Fax:
Practice Address - Street 1:140 CHANCELLOR AVENUE
Practice Address - Street 2:1B
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07112
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY106545-1101YM0800X, 104100000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health