Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0700X | Adult Development & Aging Psychologist | 1529 | NC |
N | 103TB0200X | Cognitive & Behavioral Psychologist | 1529 | NC |
N | 103G00000X | Clinical Psychologist | 1529 | NC |
N | 103TC0700X | Clinical Psychologist | 1529 | NC |
NPI | 1083695340 |
---|---|
Provider Name | Dr. Monty G. Grubb |
First Address | Wilmington, NC 28411-8724 |
Second Address | Wilmington, NC 28411-8724 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/11/2005 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1529 | PSYCHOLOGIST LICENSE NUMB (01) | NC |
6000492 | (05) | NC |