Provider Demographics
NPI:1194248112
Name:GRUBER, MARK WALTER I (LMHC, CAP)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:WALTER
Last Name:GRUBER
Suffix:I
Gender:M
Credentials:LMHC, CAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2996 NE 15TH TER
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334-4410
Mailing Address - Country:US
Mailing Address - Phone:954-993-4670
Mailing Address - Fax:
Practice Address - Street 1:100 E SAMPLE RD.
Practice Address - Street 2:#320
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064
Practice Address - Country:US
Practice Address - Phone:754-227-2431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11710101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health