Provider Demographics
NPI:1982224523
Name:GRUNBERG, VICTORIA ANN (PHD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
Last Name:GRUNBERG
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 1:1900 ARCH ST APT 503
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1535
Mailing Address - Country:US
Mailing Address - Phone:240-274-7648
Mailing Address - Fax:
Practice Address - Street 1:1 BOWDOIN ST STE 100
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4201
Practice Address - Country:US
Practice Address - Phone:240-274-7648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-23
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA11937103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program