Provider Demographics
NPI:1538842091
Name:GROOMS, SHARI NICHOLE
Entity type:Individual
Prefix:
First Name:SHARI
Middle Name:NICHOLE
Last Name:GROOMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 CALLIE JONES RD
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-5767
Mailing Address - Country:US
Mailing Address - Phone:706-934-1126
Mailing Address - Fax:
Practice Address - Street 1:822 CALLIE JONES RD
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-5767
Practice Address - Country:US
Practice Address - Phone:706-934-1126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABACB966423106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician