Healthcare Provider Details

I. General information

NPI: 1619636479
Provider Name (Legal Business Name): IVY ALYSSA GROOMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 11/14/2022
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 E FRANKLIN ST
ROCKINGHAM NC
28379-3627
US

IV. Provider business mailing address

402 HARRIS AVE
RAEFORD NC
28376-3112
US

V. Phone/Fax

Practice location:
  • Phone: 910-817-7417
  • Fax: 910-817-7218
Mailing address:
  • Phone: 910-875-5590
  • Fax: 910-875-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-27726
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP018463
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: