Provider Demographics
NPI:1770996431
Name:GRUBER, TRACY (LCSW)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:GRUBER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2828
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-2828
Mailing Address - Country:US
Mailing Address - Phone:860-869-3589
Mailing Address - Fax:
Practice Address - Street 1:10 N. MAIN STREET
Practice Address - Street 2:SUITE 210
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010
Practice Address - Country:US
Practice Address - Phone:860-869-3589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0075181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical