Provider Demographics
NPI:1891175824
Name:GROOME, LESLIE ANN (L,P,C,C,)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:GROOME
Suffix:
Gender:F
Credentials:L,P,C,C,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 SILVER LAKE RD NW
Mailing Address - Street 2:SUITE 110
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-1786
Mailing Address - Country:US
Mailing Address - Phone:651-628-9566
Mailing Address - Fax:
Practice Address - Street 1:1900 SILVER LAKE RD NW
Practice Address - Street 2:SUITE 110
Practice Address - City:NEW BRIGHTON
Practice Address - State:MN
Practice Address - Zip Code:55112-1786
Practice Address - Country:US
Practice Address - Phone:651-628-9566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01005101YP2500X
MNR 106172-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No163W00000XNursing Service ProvidersRegistered Nurse