Provider Demographics
NPI:1750100962
Name:GROVE, TAYLOR (PTA, BS, CPT, CEP)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:GROVE
Suffix:
Gender:F
Credentials:PTA, BS, CPT, CEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 CONRADT AVE
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-5253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5515 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2995
Practice Address - Country:US
Practice Address - Phone:317-880-0280
Practice Address - Fax:317-880-0296
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06006868A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant