Provider Demographics
NPI:1326450479
Name:GRONBECK, NICOLE (ATC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:GRONBECK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:CALLAGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:110 ELM ST APT. 3D
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675
Mailing Address - Country:US
Mailing Address - Phone:914-769-8311
Mailing Address - Fax:
Practice Address - Street 1:825 WESTLAKE DR
Practice Address - Street 2:
Practice Address - City:THORNWOOD
Practice Address - State:NY
Practice Address - Zip Code:10594-1945
Practice Address - Country:US
Practice Address - Phone:914-769-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT001668002255A2300X
NY002004-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer