Provider Demographics
NPI:1720784085
Name:GROOVER, MATTHEW JEREMY (CACII)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JEREMY
Last Name:GROOVER
Suffix:
Gender:M
Credentials:CACII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6326 GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-5029
Mailing Address - Country:US
Mailing Address - Phone:678-849-7021
Mailing Address - Fax:
Practice Address - Street 1:6326 GARDEN LN
Practice Address - Street 2:
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-5029
Practice Address - Country:US
Practice Address - Phone:678-849-7021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3472101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)