Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TS0200X | School Psychologist | BG1022240 | OH |
NPI | 1093116527 |
---|---|
Provider Name | Mr. Douglas Grooms |
First Address | Van Wert, OH 45891-1903 |
Second Address | Van Wert, OH 45891-1903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2014 |
Last Update Date | 16/09/2014 |