1144378555 NPI number — MRS. DOLORES B GROHMANN LMFT

Table of content: MRS. DOLORES B GROHMANN LMFT (NPI 1144378555)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144378555 NPI number — MRS. DOLORES B GROHMANN LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GROHMANN
Provider First Name:
DOLORES
Provider Middle Name:
B
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROHMANN
Provider Other First Name:
LOLITA
Provider Other Middle Name:
B
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMFT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1144378555
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4929 VAN DYKE RD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUTZ
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-924-3491
Provider Business Mailing Address Fax Number:
813-961-5919

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4322 SOUTHPARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33624-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-265-1105
Provider Business Practice Location Address Fax Number:
813-961-4406
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MT 1891 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001666500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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