Provider Demographics
NPI:1477636447
Name:GROOMS, MARTY WADE (OTR L)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:WADE
Last Name:GROOMS
Suffix:
Gender:M
Credentials:OTR L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 CRAZY DOE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38351-4718
Mailing Address - Country:US
Mailing Address - Phone:731-693-5571
Mailing Address - Fax:
Practice Address - Street 1:24 PHYSICIANS DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2070
Practice Address - Country:US
Practice Address - Phone:731-410-2357
Practice Address - Fax:731-410-2304
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN02904225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist