Provider Demographics
NPI:1760567671
Name:GRUNEBAUM, LAURIE BLUM (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:BLUM
Last Name:GRUNEBAUM
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 1:62 TRUMBULL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-1022
Mailing Address - Country:US
Mailing Address - Phone:203-776-3667
Mailing Address - Fax:203-772-1482
Practice Address - Street 1:62 TRUMBULL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-1022
Practice Address - Country:US
Practice Address - Phone:203-776-3667
Practice Address - Fax:203-772-1482
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001747103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT134296OtherVALUE OPTIONS
CT060001747CT01OtherANTHEM BC & BS