Provider Demographics
NPI:1487674008
Name:GROVE, JOHN DONELSON III (CLINICAL SOCIAL WORK)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DONELSON
Last Name:GROVE
Suffix:III
Gender:M
Credentials:CLINICAL SOCIAL WORK
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:104 RUSKIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602
Mailing Address - Country:US
Mailing Address - Phone:814-215-3999
Mailing Address - Fax:814-940-6308
Practice Address - Street 1:104 RUSKIN DRIVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602
Practice Address - Country:US
Practice Address - Phone:814-215-3999
Practice Address - Fax:814-940-6308
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0133021041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0000792941OtherHEALTH INSURANCE - B/C; B