Provider Demographics
NPI:1184136202
Name:GRUBB, DIANA (MED)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:GRUBB
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6409 ROYAL CT
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-8080
Mailing Address - Country:US
Mailing Address - Phone:972-489-7726
Mailing Address - Fax:
Practice Address - Street 1:185 S WHITE CHAPEL BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-7308
Practice Address - Country:US
Practice Address - Phone:817-552-2129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX70811101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor