MEDICARE: DR. CHRISINE PETRUS GRUBB PH.D.

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	103T00000X	Psychologist	0961	AZ

General Provider Information

NPI Number	:	1891970653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISINE PETRUS GRUBB PH.D.

Provider Business Mailing Address
First Line	:	3040 E CACTUS RD
Second Line	:	SUITE A
City	:	PHOENIX
State	:	AZ
Zip	:	85032-7196
Country	:	US
Telephone Number	:	602-494-7906
Fax Number	:

Provider Business Practice Location Address
First Line	:	3040 E CACTUS RD
Second Line	:	SUITE A
City	:	PHOENIX
State	:	AZ
Zip	:	85032-7196
Country	:	US
Telephone Number	:	602-494-7906
Fax Number	:

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

Provider Enumeration Date	:	12/29/2007
Last Update Date	:	12/29/2007

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