Healthcare Provider Details

I. General information

NPI: 1730241209
Provider Name (Legal Business Name): PENSACOLA PSYCHOLOGICAL CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 W GARDEN ST STE 370
PENSACOLA FL
32502-5641
US

IV. Provider business mailing address

229 S BAYLEN ST STE 2
PENSACOLA FL
32502-5852
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 TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN GROOM
Title or Position: OWNER
Credential: PHD
Phone: 850-433-1656