Provider Demographics
NPI:1922288273
Name:GRUBESICH, CONNIE R (LCSW)
Entity Type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:R
Last Name:GRUBESICH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 61
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72702-0061
Mailing Address - Country:US
Mailing Address - Phone:479-236-5020
Mailing Address - Fax:
Practice Address - Street 1:4241 N GABEL DR STE 3H
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5297
Practice Address - Country:US
Practice Address - Phone:479-236-5020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-04
Last Update Date:2007-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC- 5771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical