Healthcare Provider Details

I. General information

NPI: 1871083691
Provider Name (Legal Business Name): SECOND GROWTH COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2018
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 SE DIVISION ST STE 520
PORTLAND OR
97214-4672
US

IV. Provider business mailing address

PO BOX 90309
PORTLAND OR
97290-0309
US

V. Phone/Fax

Practice location:
  • Phone: 503-549-4714
  • Fax: 503-506-0411
Mailing address:
  • Phone: 503-549-4714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC3909
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberR4154
License Number StateOR

VIII. Authorized Official

Name: KELLY CARLYN GRACE
Title or Position: OWNER
Credential: MA, LMFT
Phone: 618-339-7497