Healthcare Provider Details

I. General information

NPI: 1972560308
Provider Name (Legal Business Name): CARA C GRUBER MS PT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: CARA M CHAMPION

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4480 MT HOPE RD STE A
WILLIAMSBURG MI
49690
US

IV. Provider business mailing address

603 W 10TH ST
TRAVERSE CITY MI
49684
US

V. Phone/Fax

Practice location:
  • Phone: 231-938-2425
  • Fax: 231-938-2453
Mailing address:
  • Phone: 231-342-6737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501010402
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: