=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326450479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE GRONBECK A.T.C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2014
-----------------------------------------------------
Last Update Date | 04/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 WESTLAKE DR
-----------------------------------------------------
City | THORNWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10594-1945
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-769-8311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 ELM ST APT. 3D
-----------------------------------------------------
City | WESTWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07675
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-769-8311
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 25MT00166800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 002004-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------