Provider Demographics
NPI:1801628664
Name:AVERY-GRUBEL, DOLPHIN MOON (LCPC-C)
Entity type:Individual
Prefix:
First Name:DOLPHIN
Middle Name:MOON
Last Name:AVERY-GRUBEL
Suffix:
Gender:F
Credentials:LCPC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 CHRISTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:SEDGWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04676-2812
Mailing Address - Country:US
Mailing Address - Phone:207-747-9741
Mailing Address - Fax:
Practice Address - Street 1:22 CHRISTY HILL RD
Practice Address - Street 2:
Practice Address - City:SEDGWICK
Practice Address - State:ME
Practice Address - Zip Code:04676-2812
Practice Address - Country:US
Practice Address - Phone:207-747-9741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL7648101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional