Provider Demographics
NPI:1619032380
Name:GRUESBECK, MARK RAYMOND (ATC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RAYMOND
Last Name:GRUESBECK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8829 E FAIRBROOK ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-5117
Mailing Address - Country:US
Mailing Address - Phone:480-986-4620
Mailing Address - Fax:
Practice Address - Street 1:24 WILLIE MAYS PLZ
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-2134
Practice Address - Country:US
Practice Address - Phone:415-972-1633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer