Provider Demographics
NPI:1033596747
Name:GROVE, AUTUMN
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:GROVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11185 W. 6TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80215
Mailing Address - Country:US
Mailing Address - Phone:303-239-6060
Mailing Address - Fax:
Practice Address - Street 1:11185 W. 6TH AVENUE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80215
Practice Address - Country:US
Practice Address - Phone:303-239-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL. 00134792251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPTL. 0013479OtherCOLORADO STATE PHYSICAL THERAPY LICENSE