Provider Demographics
NPI:1558034892
Name:OPTIMAL MENTAL HEALTH VIRTUAL CLINIC, PLLC
Entity Type:Organization
Organization Name:OPTIMAL MENTAL HEALTH VIRTUAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMMYJI
Authorized Official - Middle Name:
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, PMHNP-BC
Authorized Official - Phone:205-775-0080
Mailing Address - Street 1:1430 GADSDEN HWY STE 116-618
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35235-3103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 GADSDEN HWY STE 116-618
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35235-3103
Practice Address - Country:US
Practice Address - Phone:205-775-0080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty