=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790677706
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEATHER GROOM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2025
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4499 GA HIGHWAY 40 E STE A
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-9402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-513-4935
-----------------------------------------------------
Fax | 912-729-4626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4499 GA HIGHWAY 40 E STE A
-----------------------------------------------------
City | SAINT MARYS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31558-9402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-513-4935
-----------------------------------------------------
Fax | 912-729-4626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | HEATHER MARIE GROOM
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 843-513-4935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------