Provider Demographics
NPI:1104158922
Name:GROTKIEWICZ, SARAH ANN (PTA)
Entity type:Individual
Prefix:MS
First Name:SARAH
Middle Name:ANN
Last Name:GROTKIEWICZ
Suffix:
Gender:F
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:W55N453 LENOX PL APT 4
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-2548
Mailing Address - Country:US
Mailing Address - Phone:262-377-5870
Mailing Address - Fax:
Practice Address - Street 1:531 GIDDINGS AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN FALLS
Practice Address - State:WI
Practice Address - Zip Code:53085-1707
Practice Address - Country:US
Practice Address - Phone:920-550-5254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-03
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI298-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI298-19OtherWISCONSIN STATE LICENSE