Healthcare Provider Details

I. General information

NPI: 1912453432
Provider Name (Legal Business Name): SPIRITUAL GROWTH THERAPY TRAUMA AND WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6773 BONIELLO DR
BOCA RATON FL
33496-1546
US

IV. Provider business mailing address

6773 BONIELLO DR
BOCA RATON FL
33496-1546
US

V. Phone/Fax

Practice location:
  • Phone: 561-350-9567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. LISA ALLEVA
Title or Position: CEO
Credential: PH.D., LMFT
Phone: 561-350-9567