Healthcare Provider Details

I. General information

NPI: 1184548489
Provider Name (Legal Business Name): THE GROWTH ROOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

454 HIGHBROOKE BLVD
OCOEE FL
34761-3335
US

IV. Provider business mailing address

454 HIGHBROOKE BLVD
OCOEE FL
34761-3335
US

V. Phone/Fax

Practice location:
  • Phone: 352-717-4078
  • Fax:
Mailing address:
  • Phone: 352-717-4078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KELLY EVANS
Title or Position: CEO; MENTAL HEALTH THERAPIST
Credential: LCSW
Phone: 352-717-4078