Provider Demographics
NPI:1013468305
Name:GRONHOLM, LARRY JAMES (COTA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:JAMES
Last Name:GRONHOLM
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 RAYMOND LOOP
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-2899
Mailing Address - Country:US
Mailing Address - Phone:863-307-4142
Mailing Address - Fax:
Practice Address - Street 1:621 RAYMOND LOOP
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-2899
Practice Address - Country:US
Practice Address - Phone:863-307-4142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA13579224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
325120OtherNBCOT