Provider Demographics
NPI:1124164678
Name:GROENENDAAL, MIRIAN W (PT)
Entity type:Individual
Prefix:MRS
First Name:MIRIAN
Middle Name:W
Last Name:GROENENDAAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MRS
Other - First Name:MIRIAN
Other - Middle Name:W
Other - Last Name:GROENENDAAL-ZOMERSHOE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:1957 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2031
Mailing Address - Country:US
Mailing Address - Phone:541-266-7050
Mailing Address - Fax:541-266-0180
Practice Address - Street 1:1957 THOMPSON RD.
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2031
Practice Address - Country:US
Practice Address - Phone:541-266-7050
Practice Address - Fax:541-266-0180
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1813225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR182751Medicaid
OR410254301OtherREGENCE BCBS
OR182751Medicaid
OR112598Medicare ID - Type Unspecified