Healthcare Provider Details

I. General information

NPI: 1689494262
Provider Name (Legal Business Name): CONQUER ADDICTION PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 W MAIN ST STE C
MONROE WA
98272-2172
US

IV. Provider business mailing address

809 W MAIN ST STE C
MONROE WA
98272-2172
US

V. Phone/Fax

Practice location:
  • Phone: 206-552-0882
  • Fax: 844-440-2147
Mailing address:
  • Phone: 206-552-0882
  • Fax: 844-440-2147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACOB ADAM GRILLO
Title or Position: OWNER
Credential: PA-C
Phone: 206-552-0882