Healthcare Provider Details

I. General information

NPI: 1578038253
Provider Name (Legal Business Name): HAILEY GROOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 11/27/2023
Certification Date: 09/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 N HAMILTON ST
SPOKANE WA
99207-2474
US

IV. Provider business mailing address

1720 N HAMILTON ST
SPOKANE WA
99207-2474
US

V. Phone/Fax

Practice location:
  • Phone: 866-240-0808
  • Fax:
Mailing address:
  • Phone: 866-240-0808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License NumberAB61246187
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: