Provider Demographics
NPI:1740658301
Name:GRUBER, ANDREA
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:GRUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 E CROSS ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-2841
Mailing Address - Country:US
Mailing Address - Phone:734-408-1648
Mailing Address - Fax:
Practice Address - Street 1:13 E CROSS ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198-2841
Practice Address - Country:US
Practice Address - Phone:734-408-1648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501004722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist