Healthcare Provider Details

I. General information

NPI: 1699263798
Provider Name (Legal Business Name): TRACY L GROLLER PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 EATON AVE
BETHLEHEM PA
18018-1862
US

IV. Provider business mailing address

801 OSTRUM ST
BETHLEHEM PA
18015-1000
US

V. Phone/Fax

Practice location:
  • Phone: 484-526-2400
  • Fax: 484-526-3697
Mailing address:
  • Phone: 484-526-2400
  • Fax: 833-213-6428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP018733
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: