Provider Demographics
NPI:1215243142
Name:GROOME, RENA (OT)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:GROOME
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 WELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-8499
Mailing Address - Country:US
Mailing Address - Phone:817-832-5983
Mailing Address - Fax:
Practice Address - Street 1:729 WELLINGTON DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-8499
Practice Address - Country:US
Practice Address - Phone:817-832-5983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113738225X00000X
GAOT007488225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214298601Medicaid
TX849T76OtherBCBS