Provider Demographics
NPI:1942908579
Name:GRUBER, HEATHERLYNN WINCAPAW (PTA)
Entity type:Individual
Prefix:
First Name:HEATHERLYNN
Middle Name:WINCAPAW
Last Name:GRUBER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 NE SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-2347
Mailing Address - Country:US
Mailing Address - Phone:719-306-5854
Mailing Address - Fax:
Practice Address - Street 1:8355 US HIGHWAY 277
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:OK
Practice Address - Zip Code:73538-2207
Practice Address - Country:US
Practice Address - Phone:580-492-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2693225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant