Provider Demographics
NPI:1497584759
Name:GRUEBELE, DYLAN (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:GRUEBELE
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3179
Mailing Address - Country:US
Mailing Address - Phone:209-953-9601
Mailing Address - Fax:
Practice Address - Street 1:9275 GLACIER POINT DR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-3494
Practice Address - Country:US
Practice Address - Phone:209-953-9601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210134367103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool