Provider Demographics
NPI:1609042514
Name:GROTH, BETTY SUE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:BETTY SUE
Middle Name:
Last Name:GROTH
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 ALDERSON ST
Mailing Address - Street 2:
Mailing Address - City:SCHOFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54476-3614
Mailing Address - Country:US
Mailing Address - Phone:715-359-4257
Mailing Address - Fax:
Practice Address - Street 1:6001 ALDERSON ST
Practice Address - Street 2:
Practice Address - City:SCHOFIELD
Practice Address - State:WI
Practice Address - Zip Code:54476-3614
Practice Address - Country:US
Practice Address - Phone:715-359-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI812019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40103900Medicaid