Provider Demographics
NPI:1912279415
Name:GRUBB, ELIZABETH ROSE (MS, ATC)
Entity Type:Individual
Prefix:MISS
First Name:ELIZABETH
Middle Name:ROSE
Last Name:GRUBB
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 RIVERSIDE DR
Mailing Address - Street 2:14M
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-3202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3030 BROADWAY
Practice Address - Street 2:MAIL CODE 1915
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-6907
Practice Address - Country:US
Practice Address - Phone:212-854-3178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001959-012255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer