Provider Demographics
NPI:1366658650
Name:GRUBER, ELLEN J (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:J
Last Name:GRUBER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 PARK AVE NE APT 30E
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3275
Mailing Address - Country:US
Mailing Address - Phone:404-812-0997
Mailing Address - Fax:404-812-0765
Practice Address - Street 1:750 PARK AVE NE APT 30E
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-3275
Practice Address - Country:US
Practice Address - Phone:404-812-0997
Practice Address - Fax:404-812-0765
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC942101YM0800X
GALMFT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist