Healthcare Provider Details

I. General information

NPI: 1497584759
Provider Name (Legal Business Name): DYLAN GRUEBELE SCHOOL PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9275 GLACIER POINT DR
STOCKTON CA
95212-3494
US

IV. Provider business mailing address

1305 E VINE ST
LODI CA
95240-3179
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-9601
  • Fax:
Mailing address:
  • Phone: 209-953-9601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210134367
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: