Healthcare Provider Details

I. General information

NPI: 1235776683
Provider Name (Legal Business Name): CIARA DEBORAH GRUBINSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 12/22/2020
Certification Date: 12/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 WHITNEY ST
MOUNT PLEASANT MI
48858-1213
US

IV. Provider business mailing address

622 WHITNEY ST
MOUNT PLEASANT MI
48858-1213
US

V. Phone/Fax

Practice location:
  • Phone: 612-770-0529
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2601002543
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: