Provider Demographics
NPI:1609297282
Name:GRUBB, ELAINE MALLON (PCC)
Entity Type:Individual
Prefix:MRS
First Name:ELAINE
Middle Name:MALLON
Last Name:GRUBB
Suffix:
Gender:F
Credentials:PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4837 INISHEER CT
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-9170
Mailing Address - Country:US
Mailing Address - Phone:614-395-2055
Mailing Address - Fax:614-789-0300
Practice Address - Street 1:161 S LIBERTY ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:OH
Practice Address - Zip Code:43065-7619
Practice Address - Country:US
Practice Address - Phone:614-789-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0800450101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor