Healthcare Provider Details

I. General information

NPI: 1851325195
Provider Name (Legal Business Name): WENDY VIRGINIA STEPHENS-GRUBE MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 GREELEY RD
SPRINGFIELD VT
05156-8808
US

IV. Provider business mailing address

26315 GOVERNOR AVE
HARBOR CITY CA
90710-3617
US

V. Phone/Fax

Practice location:
  • Phone: 310-989-8101
  • Fax: 209-396-9030
Mailing address:
  • Phone: 310-891-2371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number34400
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number24458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: