Provider Demographics
NPI:1710352109
Name:GROOMS, MELISSA (MS)
Entity Type:Individual
Prefix:MRS
First Name:MELISSA
Middle Name:
Last Name:GROOMS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:MELISSA
Other - Middle Name:L
Other - Last Name:JEFFORDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:36745 AIKEN ROAD
Mailing Address - Street 2:
Mailing Address - City:BAYFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54814-4579
Mailing Address - Country:US
Mailing Address - Phone:715-779-3707
Mailing Address - Fax:715-779-3362
Practice Address - Street 1:36745 AIKEN ROAD
Practice Address - Street 2:
Practice Address - City:BAYFIELD
Practice Address - State:WI
Practice Address - Zip Code:54814-4579
Practice Address - Country:US
Practice Address - Phone:715-779-3707
Practice Address - Fax:715-779-3362
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2811-226101YP2500X
WI2811-266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional