Provider Demographics
NPI:1750917050
Name:GRUBER, TERRY (BS ED)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:GRUBER
Suffix:
Gender:M
Credentials:BS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5699 S FORK LITTLE CACAPON RD
Mailing Address - Street 2:
Mailing Address - City:SHANKS
Mailing Address - State:WV
Mailing Address - Zip Code:26761-9128
Mailing Address - Country:US
Mailing Address - Phone:304-257-0240
Mailing Address - Fax:
Practice Address - Street 1:5699 S FORK LITTLE CACAPON RD
Practice Address - Street 2:
Practice Address - City:SHANKS
Practice Address - State:WV
Practice Address - Zip Code:26761-9128
Practice Address - Country:US
Practice Address - Phone:304-257-0240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVE2R098400085222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist