Healthcare Provider Details

I. General information

NPI: 1649118720
Provider Name (Legal Business Name): GROW AND GLOW THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2026
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 OAKFIELD DR STE 221
BRANDON FL
33511-4924
US

IV. Provider business mailing address

11001 GOLDEN SILENCE DR
RIVERVIEW FL
33579-2341
US

V. Phone/Fax

Practice location:
  • Phone: 813-701-8161
  • Fax:
Mailing address:
  • Phone: 813-701-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BLAIR-TIFFANY MCCORMICK
Title or Position: CEO
Credential:
Phone: 813-701-8161