Healthcare Provider Details

I. General information

NPI: 1477071389
Provider Name (Legal Business Name): STEVEN JOHN GROVE LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2017
Last Update Date: 08/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 E 78TH ST STE 100
BLOOMINGTON MN
55420-1402
US

IV. Provider business mailing address

1101 E 78 ST SUITE 100
BLOOMINGTON MN
55420
US

V. Phone/Fax

Practice location:
  • Phone: 937-232-6194
  • Fax:
Mailing address:
  • Phone: 952-854-5034
  • Fax: 952-854-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: