Provider Demographics
NPI:1174738256
Name:GRUVER, RENAE MICHELLE
Entity type:Individual
Prefix:
First Name:RENAE
Middle Name:MICHELLE
Last Name:GRUVER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RENAE
Other - Middle Name:
Other - Last Name:POPKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2898 E CITADEL CT
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85298-5728
Mailing Address - Country:US
Mailing Address - Phone:480-710-8632
Mailing Address - Fax:
Practice Address - Street 1:9385 W DONALD DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-2988
Practice Address - Country:US
Practice Address - Phone:602-875-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6898225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ052151Medicaid
AZ052151Medicaid