Provider Demographics
NPI:1134217763
Name:GROCHOLSKI, TARA M (PT)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:M
Last Name:GROCHOLSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:700 GENEVA PKWY N
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147-4594
Practice Address - Country:US
Practice Address - Phone:262-249-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6118-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40366700Medicaid
WI0604410001OtherDMERC
WI005085940OtherMEDICARE