Provider Demographics
NPI:1558462416
Name:GRUENEBERG, ILENE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:GRUENEBERG
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 1:200 OAK ST
Mailing Address - Street 2:A
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2320
Mailing Address - Country:US
Mailing Address - Phone:860-657-8868
Mailing Address - Fax:860-657-8802
Practice Address - Street 1:200 OAK ST
Practice Address - Street 2:A
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2320
Practice Address - Country:US
Practice Address - Phone:860-657-8868
Practice Address - Fax:860-657-8802
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1259103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060001259CT01OtherBLUE CROSS