Provider Demographics
NPI:1689975286
Name:GROVE, MICHAEL T (LIMHP, LADC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:GROVE
Suffix:
Gender:M
Credentials:LIMHP, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N 60TH ST
Mailing Address - Street 2:CATHOLIC CHARITIES
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-3402
Mailing Address - Country:US
Mailing Address - Phone:402-554-0520
Mailing Address - Fax:402-551-8797
Practice Address - Street 1:11111 M ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-2378
Practice Address - Country:US
Practice Address - Phone:402-504-4099
Practice Address - Fax:502-504-3929
Is Sole Proprietor?:No
Enumeration Date:2010-11-12
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-876101YA0400X
NE8800101YM0800X
NE900101YA0400X
NE952101YA0400X
NE1950101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE092619Medicare UPIN