MEDICARE: DR. MONTY G. GRUBB PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TA0700X	Adult Development & Aging Psychologist	1529	NC
2	103TB0200X	Cognitive & Behavioral Psychologist	1529	NC
3	103TC0700X	Clinical Psychologist	1529	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1529	OTHER	NC	PSYCHOLOGIST LICENSE NUMB

General Provider Information

NPI Number	:	1083695340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MONTY G. GRUBB PHD

Provider Business Mailing Address
First Line	:	7946 MARKET ST
Second Line	:	SUITE 500
City	:	WILMINGTON
State	:	NC
Zip	:	28411-8724
Country	:	US
Telephone Number	:	901-686-4300
Fax Number	:	910-686-3303

Provider Business Practice Location Address
First Line	:	7946 MARKET ST
Second Line	:	SUITE 500
City	:	WILMINGTON
State	:	NC
Zip	:	28411-8724
Country	:	US
Telephone Number	:	901-686-4300
Fax Number	:	910-686-3303

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	09/11/2025

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