Healthcare Provider Details

I. General information

NPI: 1255328795
Provider Name (Legal Business Name): JOHANNA GROVER P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N MAIN ST
SHAWANO WI
54166-2356
US

IV. Provider business mailing address

116 N MAIN ST
SHAWANO WI
54166-2356
US

V. Phone/Fax

Practice location:
  • Phone: 715-526-7370
  • Fax: 715-526-7294
Mailing address:
  • Phone: 715-526-7370
  • Fax: 715-526-7294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4680-024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: