Provider Demographics
NPI:1740090927
Name:GROGG, TYLER
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:GROGG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21261 S 227TH PL
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-2841
Mailing Address - Country:US
Mailing Address - Phone:801-891-0821
Mailing Address - Fax:
Practice Address - Street 1:1240 BROADWAY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-4994
Practice Address - Country:US
Practice Address - Phone:619-841-1310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95400841163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health