Healthcare Provider Details

I. General information

NPI: 1124581160
Provider Name (Legal Business Name): SELENA MARIE GROOMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SELENA MARIE PETTIT

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S 4TH ST
NEWARK OH
43055-5002
US

IV. Provider business mailing address

140 E TOWN ST STE 1450
COLUMBUS OH
43215-6601
US

V. Phone/Fax

Practice location:
  • Phone: 380-201-1313
  • Fax:
Mailing address:
  • Phone: 614-639-6590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberQMHS
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: