Provider Demographics
NPI:1962572990
Name:GROOMS, KIM (LMSW)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:GROOMS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 HAMMOND BLVD
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8632
Mailing Address - Country:US
Mailing Address - Phone:505-742-3013
Mailing Address - Fax:
Practice Address - Street 1:1600 SUTTER PL
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4611
Practice Address - Country:US
Practice Address - Phone:505-769-4490
Practice Address - Fax:505-935-0011
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2867951041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45822891Medicaid