Healthcare Provider Details

I. General information

NPI: 1518896406
Provider Name (Legal Business Name): BRANDON GROVER OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/16/2026
Certification Date: 05/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 GRANT AVE
OMRO WI
54963-1342
US

IV. Provider business mailing address

115 E WASHINGTON ST APT 305
APPLETON WI
54911-5442
US

V. Phone/Fax

Practice location:
  • Phone: 920-685-2755
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number9065-26
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: