Provider Demographics
NPI:1275540056
Name:GROTHUES, CAROL A (PHD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:A
Last Name:GROTHUES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 DAISY PATH
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737-4574
Mailing Address - Country:US
Mailing Address - Phone:903-918-8593
Mailing Address - Fax:903-759-2402
Practice Address - Street 1:911 W LOOP 281
Practice Address - Street 2:SUITE 302
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-2900
Practice Address - Country:US
Practice Address - Phone:903-759-2402
Practice Address - Fax:903-759-2570
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25603103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX611004Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER