Provider Demographics
NPI:1851325195
Name:STEPHENS-GRUBE, WENDY VIRGINIA (MFT)
Entity Type:Individual
Prefix:
First Name:WENDY
Middle Name:VIRGINIA
Last Name:STEPHENS-GRUBE
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26315 GOVERNOR AVE
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3617
Mailing Address - Country:US
Mailing Address - Phone:310-891-2371
Mailing Address - Fax:
Practice Address - Street 1:651 GREELEY RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VT
Practice Address - Zip Code:05156-8808
Practice Address - Country:US
Practice Address - Phone:310-989-8101
Practice Address - Fax:209-396-9030
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34400106H00000X
CA24458103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist