Provider Demographics
NPI:1386676708
Name:GROHOLSKI, AL (MOT)
Entity Type:Individual
Prefix:MR
First Name:AL
Middle Name:
Last Name:GROHOLSKI
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:DEBARY
Mailing Address - State:FL
Mailing Address - Zip Code:32713-2323
Mailing Address - Country:US
Mailing Address - Phone:561-818-0691
Mailing Address - Fax:561-790-1918
Practice Address - Street 1:50 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:DEBARY
Practice Address - State:FL
Practice Address - Zip Code:32713-2323
Practice Address - Country:US
Practice Address - Phone:561-818-0691
Practice Address - Fax:561-790-1918
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 8550225X00000X
FLOT8550225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE2752Medicare ID - Type UnspecifiedPART B