Provider Demographics
NPI:1659881167
Name:DEGROOT, DAWN MAE (PTA)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MAE
Last Name:DEGROOT
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 1:537 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4802
Mailing Address - Country:US
Mailing Address - Phone:719-310-4167
Mailing Address - Fax:
Practice Address - Street 1:8015 S SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:CA
Practice Address - Zip Code:90045-2940
Practice Address - Country:US
Practice Address - Phone:310-991-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA0012192208100000X
CAPTA48746208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation