Healthcare Provider Details

I. General information

NPI: 1912756792
Provider Name (Legal Business Name): COREY JO GROOMS CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 COURT ST
PORTSMOUTH OH
45662-3932
US

IV. Provider business mailing address

2065 STONERIDGE DR
CIRCLEVILLE OH
43113-8956
US

V. Phone/Fax

Practice location:
  • Phone: 740-354-6685
  • Fax: 740-876-4005
Mailing address:
  • Phone: 740-500-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberAPS.005750
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: