Healthcare Provider Details

I. General information

NPI: 1013524149
Provider Name (Legal Business Name): GROW, EMPOWER, TRANSFORM THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 N MACDILL AVE STE 116
TAMPA FL
33607-2284
US

IV. Provider business mailing address

PO BOX 10192
TAMPA FL
33679-0192
US

V. Phone/Fax

Practice location:
  • Phone: 813-563-8227
  • Fax:
Mailing address:
  • Phone: 813-563-8227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. DENISE D MOORE
Title or Position: OWNER, CLINICAL DIRECTOR
Credential: LMHC, QS
Phone: 813-563-8227