Provider Demographics
NPI:1063928034
Name:GRONOTTE, MADELINE ANN
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:ANN
Last Name:GRONOTTE
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 1:580 LINCOLN PARK BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-3556
Mailing Address - Country:US
Mailing Address - Phone:937-499-1435
Mailing Address - Fax:937-499-1468
Practice Address - Street 1:580 LINCOLN PARK BLVD STE 105
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-3556
Practice Address - Country:US
Practice Address - Phone:937-499-1435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-28
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid