Provider Demographics
NPI:1285859843
Name:GROGAN, CHARLES DIETRICH (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DIETRICH
Last Name:GROGAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5922 CATTLEMEN LANE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232
Mailing Address - Country:US
Mailing Address - Phone:941-378-8977
Mailing Address - Fax:941-378-8967
Practice Address - Street 1:5922 CATTLEMEN LANE
Practice Address - Street 2:SUITE 100
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34232
Practice Address - Country:US
Practice Address - Phone:941-378-8977
Practice Address - Fax:941-378-8967
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA19756225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant