Provider Demographics
NPI:1467729889
Name:GROLLEY, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:GROLLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12833-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5317 SACANDAGA RD
Practice Address - Street 2:
Practice Address - City:GALWAY
Practice Address - State:NY
Practice Address - Zip Code:12074-2423
Practice Address - Country:US
Practice Address - Phone:518-882-1291
Practice Address - Fax:518-882-5250
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0087771235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist