Healthcare Provider Details

I. General information

NPI: 1184717027
Provider Name (Legal Business Name): KEVIN N GROOM PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 SOUTH PALAFOX STREET SUITE 300
PENSACOLA FL
32502
US

IV. Provider business mailing address

890 SOUTH PALAFOX STREET SUITE 300
PENSACOLA FL
32502
US

V. Phone/Fax

Practice location:
  • Phone: 850-433-1656
  • Fax: 850-433-1996
Mailing address:
  • Phone: 850-433-1656
  • Fax: 850-433-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number1138
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY6326
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: