Provider Demographics
NPI:1336770734
Name:GROOMER, EVAN THOMAS
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:THOMAS
Last Name:GROOMER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 EARHART BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70125-1955
Mailing Address - Country:US
Mailing Address - Phone:504-522-4475
Mailing Address - Fax:
Practice Address - Street 1:4150 EARHART BLVD
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70125-1955
Practice Address - Country:US
Practice Address - Phone:504-522-4475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7925101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional