Basic Information
| Provider Information | |||||||||
| NPI: | 1548272891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GROVES | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 ANGELS PATH RD | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541154050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203382855 | ||||||||
| FaxNumber: | 9203389270 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 ANGELS PATH RD | ||||||||
| Address2: | |||||||||
| City: | DE PERE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 541154050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9203382855 | ||||||||
| FaxNumber: | 9203389270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 01/14/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 1568-057 | WI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 001244550 | 01 | WI | MEDICARE | OTHER | 39266100 | 05 | WI | MEDICAID |