Provider Demographics
NPI:1619647682
Name:GRUBER, MARISA N (BCBA, LBA)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:N
Last Name:GRUBER
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 Q ST NW APT 119
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-4301
Mailing Address - Country:US
Mailing Address - Phone:248-990-4080
Mailing Address - Fax:
Practice Address - Street 1:6601 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20720-3324
Practice Address - Country:US
Practice Address - Phone:301-755-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLBA114103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst