=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801379219
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE NIKOLE GROOMAN AMFT 477258
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2018
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1191 CENTRAL BLVD STE A
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94513-2253
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-223-7123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 E LELAND RD STE C
-----------------------------------------------------
City | PITTSBURG
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94565-4954
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-550-0103
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | AMFT477258
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------