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General NPI Number Information
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NPI Number | 1356632087
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Entity Type | Individual
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Provider Name | CANDICE RAE GRONBERG
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Gender | Female
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Dates
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Enumeration Date | 04/28/2011
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Last Update Date | 04/28/2011
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Provider Practice Location Address
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Address Line | 4 ROBERTS ROAD
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City | LANDER
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State | WY
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Zip | 82520-1401
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Country | US
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Telephone | 307-332-9122
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Fax | 307-332-9122
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Provider Business Mailing Address
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Address Line | PO BOX 1401 4 ROBERTS ROAD
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City | LANDER
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State | WY
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Zip | 82520-1401
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Country | US
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Telephone | 307-332-9122
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Fax | 307-332-9122
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 114858300
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License Number State | WY
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