Provider Demographics
NPI:1205597119
Name:GRONAU, MATTHEW CRAIG (LAT, ATC)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:CRAIG
Last Name:GRONAU
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4735 SAND RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-1709
Mailing Address - Country:US
Mailing Address - Phone:352-428-7849
Mailing Address - Fax:
Practice Address - Street 1:1515 W BEARSS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-1111
Practice Address - Country:US
Practice Address - Phone:813-920-2288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL35962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer