| Doctor Name: | CANDICE RAE GRONBERG |
| NPI Number: | 1356632087 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 114858300 |
| Business Practice Address: | 4 Roberts Road Lander, WY - 825201401 |
| Business Phone Number: | 3073329122 |
| Business Fax Number: | 3073329122 |
| Mailing Address: | Po Box 1401, 4 Roberts Road LANDER |
| State: | WY |
| Postal Code: | 825201401 |
| Phone Number: | 3073329122 |
| Fax Number: | 3073329122 |
| NPI Enumeration Date: | 04/28/2011 |
| NPI Last Update Date: | 04/28/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 385HR2060X |
| License Number: | 114858300 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WY |
| Taxonomy Type: | Respite Care Facility |
| Taxonomy Classification: | Respite Care |
| Taxonomy Specialization: | Respite Care, Mental Retardation and/or Developmental Disabilities, Child |
| Taxonomy Definition: | A facility or distinct part of a facility that provides short term, residential care to children, diagnosed with mental retardation and/or developmental disabilities as respite for the regular caregivers. |