Provider Demographics
NPI:1891299798
Name:GROOM, MARISSA NORA (MS)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:NORA
Last Name:GROOM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:GROOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:3815 E MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-2488
Mailing Address - Country:US
Mailing Address - Phone:630-584-7530
Mailing Address - Fax:
Practice Address - Street 1:3815 E MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-2488
Practice Address - Country:US
Practice Address - Phone:630-584-7530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
IL146.014241235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist