Provider Demographics
NPI:1619636479
Name:GROOMS, IVY ALYSSA
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:ALYSSA
Last Name:GROOMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3112
Mailing Address - Country:US
Mailing Address - Phone:910-875-5590
Mailing Address - Fax:910-875-5008
Practice Address - Street 1:232 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-3627
Practice Address - Country:US
Practice Address - Phone:910-817-7417
Practice Address - Fax:910-817-7218
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-27726101YA0400X, 101YA0400X
NCP0184631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical