Provider Demographics
NPI:1659609949
Name:GROTH, GREGORY R (LMT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:R
Last Name:GROTH
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
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Mailing Address - Street 1:63 LONG TREE LN
Mailing Address - Street 2:APT 2
Mailing Address - City:MORICHES
Mailing Address - State:NY
Mailing Address - Zip Code:11955-2047
Mailing Address - Country:US
Mailing Address - Phone:631-909-2334
Mailing Address - Fax:631-281-0990
Practice Address - Street 1:2 CORACI BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-4833
Practice Address - Country:US
Practice Address - Phone:631-281-0606
Practice Address - Fax:631-281-0990
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY019137225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist