Provider Demographics
NPI:1164739538
Name:GROCH, ANDY JOHN (LMP, FT)
Entity Type:Individual
Prefix:MR
First Name:ANDY
Middle Name:JOHN
Last Name:GROCH
Suffix:
Gender:M
Credentials:LMP, FT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94 BAY STREET
Mailing Address - Street 2:UNIT #406
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-3039
Mailing Address - Country:US
Mailing Address - Phone:206-683-1869
Mailing Address - Fax:
Practice Address - Street 1:94 BAY STREET
Practice Address - Street 2:UNIT #406
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-3039
Practice Address - Country:US
Practice Address - Phone:206-683-1869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00016840225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist