Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YM0800X | Mental Health Counselor |
NPI | 1003152943 |
---|---|
Provider Name | Angela Gruber |
First Address | Panama City, FL 32405-5412 |
Second Address | Panama City, FL 32405-5412 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2012 |
Last Update Date | 21/12/2012 |