Provider Demographics
NPI:1619493210
Name:GROOM, EMERSON (RADT1)
Entity Type:Individual
Prefix:
First Name:EMERSON
Middle Name:
Last Name:GROOM
Suffix:
Gender:M
Credentials:RADT1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 S BRISTOL ST
Mailing Address - Street 2:8Q
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-6727
Mailing Address - Country:US
Mailing Address - Phone:714-583-1565
Mailing Address - Fax:
Practice Address - Street 1:2101 E 1ST ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-4007
Practice Address - Country:US
Practice Address - Phone:714-581-9181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1242690217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)