MEDICARE: MARY GRUBB MSW, LCSW

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	1041C0700X	Clinical Social Worker	33006027A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	33006027A	OTHER	IN	LSW

General Provider Information

NPI Number	:	1720419815
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY GRUBB MSW, LCSW

Provider Business Mailing Address
First Line	:	1901 OLDS CT
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-2529
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 OLDS CT
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-2529
Country	:	US
Telephone Number	:	765-453-8547
Fax Number	:

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

Provider Enumeration Date	:	11/28/2013
Last Update Date	:	11/11/2015

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