Healthcare Provider Details

I. General information

NPI: 1457147076
Provider Name (Legal Business Name): NEW GROWTH STA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2025
Last Update Date: 04/18/2025
Certification Date: 04/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SOUTHPARK BLVD STE 208
ST AUGUSTINE FL
32086-5179
US

IV. Provider business mailing address

150 SOUTHPARK BLVD STE 208
ST AUGUSTINE FL
32086-5179
US

V. Phone/Fax

Practice location:
  • Phone: 732-575-8874
  • Fax:
Mailing address:
  • Phone: 732-575-8874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAITLIN FAY
Title or Position: MGR
Credential: LCSW
Phone: 732-575-8874