Provider Demographics
NPI:1215757240
Name:GROOME, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:GROOME
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 VREELAND AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1546
Mailing Address - Country:US
Mailing Address - Phone:973-985-9599
Mailing Address - Fax:
Practice Address - Street 1:3458 NEELY RD
Practice Address - Street 2:
Practice Address - City:MC GUIRE AFB
Practice Address - State:NJ
Practice Address - Zip Code:08641-5312
Practice Address - Country:US
Practice Address - Phone:609-754-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00239100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant