Provider Demographics
NPI:1841307246
Name:GROTA, CARL D (PT)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:D
Last Name:GROTA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:STURGEON BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54235-1401
Mailing Address - Country:US
Mailing Address - Phone:920-743-5566
Mailing Address - Fax:
Practice Address - Street 1:1300 EGG HARBOR RD STE 152
Practice Address - Street 2:
Practice Address - City:STURGEON BAY
Practice Address - State:WI
Practice Address - Zip Code:54235-1248
Practice Address - Country:US
Practice Address - Phone:920-746-0410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5783-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40294800Medicaid
WI40294800Medicaid