Provider Demographics
NPI:1124284013
Name:GROTE, TERESA M (DPT)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:GROTE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:M
Other - Last Name:HIBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1519 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2918
Mailing Address - Country:US
Mailing Address - Phone:803-779-8327
Mailing Address - Fax:803-799-3603
Practice Address - Street 1:1519 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2918
Practice Address - Country:US
Practice Address - Phone:803-779-8327
Practice Address - Fax:803-799-3603
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2010-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5786225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5786OtherPT LICENSE
SC426542Medicare PIN