Provider Demographics
NPI:1902058704
Name:GROVE-SUPPOK, BETH (OT)
Entity Type:Individual
Prefix:MRS
First Name:BETH
Middle Name:
Last Name:GROVE-SUPPOK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:MISS
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:GROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OT
Mailing Address - Street 1:625 LINCOLN AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:N CHARLEROI
Mailing Address - State:PA
Mailing Address - Zip Code:15022
Mailing Address - Country:US
Mailing Address - Phone:724-483-3610
Mailing Address - Fax:724-489-4758
Practice Address - Street 1:223 S PLEASANT STREET SUITE 301
Practice Address - Street 2:OSPTA SOMERSET
Practice Address - City:SOMERSET
Practice Address - State:PA
Practice Address - Zip Code:15510
Practice Address - Country:US
Practice Address - Phone:412-751-0040
Practice Address - Fax:724-483-3154
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC010191225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102211357 0001Medicaid
PA396610Medicare Oscar/Certification
PA102211357 0001Medicaid