Healthcare Provider Details

I. General information

NPI: 1245143262
Provider Name (Legal Business Name): KELLY MARIE GRUBER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2026
Last Update Date: 09/23/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18704 N 51ST DR
GLENDALE AZ
85308-4628
US

IV. Provider business mailing address

18704 N 51ST DR
GLENDALE AZ
85308-4628
US

V. Phone/Fax

Practice location:
  • Phone: 623-670-3466
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-15764
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: