Provider Demographics
NPI:1780933481
Name:GROVE, CHARLES E (PHD, MSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:GROVE
Suffix:
Gender:M
Credentials:PHD, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 LOCUST ST
Mailing Address - Street 2:MAZZONI CENTER FAMILY & COMMUNITY MEDICINE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5507
Mailing Address - Country:US
Mailing Address - Phone:215-563-0658
Mailing Address - Fax:
Practice Address - Street 1:1900 S ISEMINGER ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2207
Practice Address - Country:US
Practice Address - Phone:267-847-4148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-10
Last Update Date:2017-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
PASW 1315891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)