Healthcare Provider Details

I. General information

NPI: 1215657952
Provider Name (Legal Business Name): MARIE ELIZABETH GRUBE PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2022
Last Update Date: 09/01/2022
Certification Date: 09/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MASONIC DR
ELIZABETHTOWN PA
17022-2199
US

IV. Provider business mailing address

1 MASONIC DR
ELIZABETHTOWN PA
17022-2199
US

V. Phone/Fax

Practice location:
  • Phone: 717-367-1121
  • Fax:
Mailing address:
  • Phone: 717-367-1121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTEI000601
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: