Provider Demographics
NPI:1851607147
Name:SMITH GRUEBERT, AMY (LMT)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:SMITH GRUEBERT
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51546 HWY 97 LAPINE SQUARE 7N
Mailing Address - Street 2:
Mailing Address - City:LAPINE
Mailing Address - State:OR
Mailing Address - Zip Code:97739-0000
Mailing Address - Country:US
Mailing Address - Phone:541-536-3300
Mailing Address - Fax:
Practice Address - Street 1:51546 HWY 97
Practice Address - Street 2:LAPINE SQUARE 7N
Practice Address - City:LA PINE
Practice Address - State:OR
Practice Address - Zip Code:97739-8957
Practice Address - Country:US
Practice Address - Phone:541-536-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist