Provider Demographics
NPI:1902133804
Name:GROVER, THOMAS GLEN (PTA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:GLEN
Last Name:GROVER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 55TH PL NE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98422-3253
Mailing Address - Country:US
Mailing Address - Phone:253-568-6748
Mailing Address - Fax:
Practice Address - Street 1:3850 S MERIDIAN
Practice Address - Street 2:SUITE 03
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3701
Practice Address - Country:US
Practice Address - Phone:253-845-9098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-13
Last Update Date:2009-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60044890225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant