Provider Demographics
NPI:1356632087
Name:GRONBERG, CANDICE RAE
Entity Type:Individual
Prefix:
First Name:CANDICE
Middle Name:RAE
Last Name:GRONBERG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1401
Mailing Address - Street 2:4 ROBERTS ROAD
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-1401
Mailing Address - Country:US
Mailing Address - Phone:307-332-9122
Mailing Address - Fax:307-332-9122
Practice Address - Street 1:4 ROBERTS ROAD
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-1401
Practice Address - Country:US
Practice Address - Phone:307-332-9122
Practice Address - Fax:307-332-9122
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY114858300385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child