Provider Demographics
NPI:1790354785
Name:GRUBBS, ANGELA MARIE (PTA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MARIE
Last Name:GRUBBS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:467 CORMORANT CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-8193
Mailing Address - Country:US
Mailing Address - Phone:765-586-0947
Mailing Address - Fax:
Practice Address - Street 1:2741 N SALISBURY ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1499
Practice Address - Country:US
Practice Address - Phone:765-464-5106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004299A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant