Provider Demographics
NPI:1760036289
Name:GROSE, JOHANNA (OT)
Entity Type:Individual
Prefix:
First Name:JOHANNA
Middle Name:
Last Name:GROSE
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 SATELLITE BLVD STE 2250
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5047
Mailing Address - Country:US
Mailing Address - Phone:800-381-2195
Mailing Address - Fax:888-381-0822
Practice Address - Street 1:889 BELL RD STE A
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-3101
Practice Address - Country:US
Practice Address - Phone:800-381-2195
Practice Address - Fax:888-381-0822
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOT6209225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist