Provider Demographics
NPI:1124581160
Name:GROOMS, SELENA MARIE
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:MARIE
Last Name:GROOMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SELENA
Other - Middle Name:MARIE
Other - Last Name:PETTIT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:140 E TOWN ST STE 1450
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-6601
Mailing Address - Country:US
Mailing Address - Phone:614-639-6590
Mailing Address - Fax:
Practice Address - Street 1:30 S 4TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-5002
Practice Address - Country:US
Practice Address - Phone:380-201-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
QMHS101YM0800X
OH171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health