Healthcare Provider Details

I. General information

NPI: 1164073102
Provider Name (Legal Business Name): THE GROWTH PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 GRACELAND DR SE STE B
ALBUQUERQUE NM
87108-2778
US

IV. Provider business mailing address

2813 ALVARADO DR NE
ALBUQUERQUE NM
87110-3229
US

V. Phone/Fax

Practice location:
  • Phone: 575-740-1689
  • Fax:
Mailing address:
  • Phone: 575-740-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KASSANDRA WILLIAMS
Title or Position: OWNER
Credential: LMFT
Phone: 575-740-1689