Healthcare Provider Details

I. General information

NPI: 1558056911
Provider Name (Legal Business Name): GROW WITH ME- CRECIENDO JUNTOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 S FRONTAGE RD STE 103
NIPOMO CA
93444-5626
US

IV. Provider business mailing address

720 S FRONTAGE RD STE 103
NIPOMO CA
93444-5626
US

V. Phone/Fax

Practice location:
  • Phone: 805-242-6522
  • Fax: 805-540-5890
Mailing address:
  • Phone: 805-242-6522
  • Fax: 805-540-5890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: BLANCA N GARCIA
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 805-598-7175