Provider Demographics
NPI:1417579319
Name:GRUBISIC, CARRIE ANNE
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANNE
Last Name:GRUBISIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:ANNE
Other - Last Name:WARE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15333 CULVER DR STE 340-122
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3078
Mailing Address - Country:US
Mailing Address - Phone:949-312-1920
Mailing Address - Fax:
Practice Address - Street 1:15333 CULVER DR STE 340-122
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3078
Practice Address - Country:US
Practice Address - Phone:949-312-1920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132250106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist