1902058704 NPI number — MRS. BETH GROVE SUPPOK OT

Table of content: MRS. BETH GROVE SUPPOK OT (NPI 1902058704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902058704 NPI number — MRS. BETH GROVE SUPPOK OT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUPPOK
Provider First Name:
BETH
Provider Middle Name:
GROVE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GROVE
Provider Other First Name:
BETH
Provider Other Middle Name:
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
OT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902058704
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/21/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 LINCOLN AVE
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
N CHARLEROI
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-483-3610
Provider Business Mailing Address Fax Number:
724-489-4758

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 S PLEASANT STREET SUITE 301
Provider Second Line Business Practice Location Address:
OSPTA SOMERSET
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15510
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-751-0040
Provider Business Practice Location Address Fax Number:
724-483-3154
Provider Enumeration Date:
10/13/2008

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: 225X00000X , with the licence number:  OC010191 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102211357 0001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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