Provider Demographics
NPI:1679625826
Name:GROOSE, SUSAN DAWN (PT)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DAWN
Last Name:GROOSE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 HIGHWAY AA
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:MO
Mailing Address - Zip Code:65032-4030
Mailing Address - Country:US
Mailing Address - Phone:573-498-6155
Mailing Address - Fax:
Practice Address - Street 1:3308 W EDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6891
Practice Address - Country:US
Practice Address - Phone:573-638-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO11185225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist