Provider Demographics
NPI:1548628514
Name:GROSCHE, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:GROSCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11350 19TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:ND
Mailing Address - Zip Code:58722-9504
Mailing Address - Country:US
Mailing Address - Phone:701-833-1155
Mailing Address - Fax:
Practice Address - Street 1:11350 19TH AVE NW
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:ND
Practice Address - Zip Code:58722-9504
Practice Address - Country:US
Practice Address - Phone:701-833-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-05
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND805225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist