Provider Demographics
NPI:1356880421
Name:GRUBER VELLA, KERRY LYN (PHD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:LYN
Last Name:GRUBER VELLA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:KERRY
Other - Middle Name:LYN
Other - Last Name:GRUBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:5657 NEW INDEPENDENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-8745
Mailing Address - Country:US
Mailing Address - Phone:781-332-2989
Mailing Address - Fax:
Practice Address - Street 1:5657 NEW INDEPENDENCE PKWY
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-8745
Practice Address - Country:US
Practice Address - Phone:781-332-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9804103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical