Healthcare Provider Details

I. General information

NPI: 1174992234
Provider Name (Legal Business Name): RACHEL GRUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 11/09/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1272 VIRGIL LANGFORD ROAD SUITE 101
WATKINSVILLE GA
30677
US

IV. Provider business mailing address

3500 DEPAUW BLVD STE 3070
INDIANAPOLIS IN
46268-6135
US

V. Phone/Fax

Practice location:
  • Phone: 706-449-0273
  • Fax:
Mailing address:
  • Phone: 855-324-0885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11520047
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: