Provider Demographics
NPI:1477161537
Name:GROTH, ASHLEY MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:GROTH
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12031 N GRANVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53097-2511
Mailing Address - Country:US
Mailing Address - Phone:262-573-8616
Mailing Address - Fax:
Practice Address - Street 1:5595 COUNTY ROAD Z
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-9224
Practice Address - Country:US
Practice Address - Phone:262-306-2112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI15071225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist