Provider Demographics
NPI:1730241209
Name:PENSACOLA PSYCHOLOGICAL CLINIC PA
Entity type:Organization
Organization Name:PENSACOLA PSYCHOLOGICAL CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:850-433-1656
Mailing Address - Street 1:229 S BAYLEN ST
Mailing Address - Street 2:STE 2
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32502-5852
Mailing Address - Country:US
Mailing Address - Phone:850-433-1656
Mailing Address - Fax:850-433-1996
Practice Address - Street 1:3 W GARDEN ST
Practice Address - Street 2:STE 370
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5641
Practice Address - Country:US
Practice Address - Phone:850-433-1656
Practice Address - Fax:850-433-1996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty