MEDICARE: COLLEEN GROMBALA PT, DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5501303695	MI

General Provider Information

NPI Number	:	1538968961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEEN GROMBALA PT, DPT

Provider Business Mailing Address
First Line	:	355 E 14 MILE RD APT 7
Second Line	:
City	:	BIRMINGHAM
State	:	MI
Zip	:	48009-5103
Country	:	US
Telephone Number	:	248-230-0048
Fax Number	:

Provider Business Practice Location Address
First Line	:	6785 23 MILE RD
Second Line	:
City	:	SHELBY TOWNSHIP
State	:	MI
Zip	:	48316-4414
Country	:	US
Telephone Number	:	586-788-7107
Fax Number	:	586-371-2037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2025
Last Update Date	:	03/10/2025

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