Provider Demographics
NPI:1508870189
Name:GROVE, COLIN R (PT, DPT, MS, PHD)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:R
Last Name:GROVE
Suffix:
Gender:M
Credentials:PT, DPT, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 CLIFTON RD NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-1004
Mailing Address - Country:US
Mailing Address - Phone:404-712-8685
Mailing Address - Fax:
Practice Address - Street 1:6630 UNIVERSITY AVE
Practice Address - Street 2:REHABILITATION CLINIC - MIDDLETON MAIL CODE 9430
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-3036
Practice Address - Country:US
Practice Address - Phone:608-263-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0170622251N0400X
WI4776-24225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
No225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4776-24OtherPT NEURO REHAB