=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124526678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOM TO GROW: THERAPY, SUPERVISION, CONSULTATION, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2018
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8150 US HIGHWAY 287
-----------------------------------------------------
City | CHILDRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79201-7152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-536-3644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 804 COMBS ST
-----------------------------------------------------
City | QUANAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79252-4444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARY SUE GREEN
-----------------------------------------------------
Credential | PH.D., LMFT
-----------------------------------------------------
Telephone | 940-536-3644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 201547
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------