Provider Demographics
NPI:1720554876
Name:GRUMBACH, GIESELA (PHD)
Entity Type:Individual
Prefix:
First Name:GIESELA
Middle Name:
Last Name:GRUMBACH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:GIESELA
Other - Middle Name:
Other - Last Name:GRUMBACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:GIESELA GRUMBACHBLUE
Mailing Address - Street 1:18021 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-2940
Mailing Address - Country:US
Mailing Address - Phone:773-412-7390
Mailing Address - Fax:
Practice Address - Street 1:2601 LINCOLN HWY STE 101
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1844
Practice Address - Country:US
Practice Address - Phone:773-727-9417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490077831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical