MEDICARE: PERSONAL GROWTH THERAPY CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1790423564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PERSONAL GROWTH THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	7709 JACKSON SPRINGS RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-3417
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7709 JACKSON SPRINGS RD
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33615-3417
Country	:	US
Telephone Number	:	813-390-9642
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAOLA HOLGUIN
Credential	:	LMHC
Telephone Number	:	813-390-9642

Provider Enumeration Date	:	05/23/2022
Last Update Date	:	05/23/2022

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