| Doctor Name: | MR. DOUGLAS GROOMS |
| NPI Number: | 1093116527 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | NCSP |
| License Number: | BG1022240 |
| Business Practice Address: | 205 W Crawford St Van Wert, OH - 458911903 |
| Business Phone Number: | 4192382180 |
| Business Fax Number: | 4192380526 |
| Mailing Address: | 205 W Crawford St, VAN WERT |
| State: | OH |
| Postal Code: | 458911903 |
| Phone Number: | 4192382180 |
| Fax Number: | 4192380526 |
| NPI Enumeration Date: | 09/16/2014 |
| NPI Last Update Date: | 09/16/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TS0200X |
| License Number: | BG1022240 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OH |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | School |
| Taxonomy Definition: | |