Provider Demographics
NPI:1447304084
Name:GROBECKER, JOANN RENE (OT)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:RENE
Last Name:GROBECKER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:J
Other - Middle Name:RENE
Other - Last Name:GROBECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OT
Mailing Address - Street 1:8304 MESA TOP RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-3779
Mailing Address - Country:US
Mailing Address - Phone:505-459-2934
Mailing Address - Fax:505-343-1363
Practice Address - Street 1:8304 MESA TOP RD NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-3779
Practice Address - Country:US
Practice Address - Phone:505-459-2934
Practice Address - Fax:505-343-1363
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1778174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM4268352Medicaid