Provider Demographics
NPI:1508196304
Name:GROGAN, TINA GRAHAM (LMT, MMP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:GRAHAM
Last Name:GROGAN
Suffix:
Gender:F
Credentials:LMT, MMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PAMELA LN
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3063
Mailing Address - Country:US
Mailing Address - Phone:843-412-8133
Mailing Address - Fax:
Practice Address - Street 1:101 PAMELA LN
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3063
Practice Address - Country:US
Practice Address - Phone:843-412-8133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-30
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMA-3634225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist