Provider Demographics
NPI:1902163785
Name:GRUBER, BASHA
Entity Type:Individual
Prefix:
First Name:BASHA
Middle Name:
Last Name:GRUBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 RIVER AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5200
Mailing Address - Country:US
Mailing Address - Phone:732-833-3723
Mailing Address - Fax:888-247-4390
Practice Address - Street 1:761 RIVER AVE
Practice Address - Street 2:SUITE D
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5200
Practice Address - Country:US
Practice Address - Phone:732-833-3723
Practice Address - Fax:888-247-4390
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-11-9269103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst