Provider Demographics
NPI:1093116527
Name:GROOMS, DOUGLAS (NCSP)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:
Last Name:GROOMS
Suffix:
Gender:M
Credentials:NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-1903
Mailing Address - Country:US
Mailing Address - Phone:419-238-2180
Mailing Address - Fax:419-238-0526
Practice Address - Street 1:205 W CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-1903
Practice Address - Country:US
Practice Address - Phone:419-238-2180
Practice Address - Fax:419-238-0526
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-16
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBG1022240103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool