Provider Demographics
NPI:1679795405
Name:GROUPP, SALLY E
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:E
Last Name:GROUPP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 DEPOT RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1211
Practice Address - Country:US
Practice Address - Phone:207-781-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT54174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEPT54OtherPHYSICAL THERAPIST