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General NPI Number Information
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NPI Number | 1164073102
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Entity Type | Organization
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Legal Business Name | THE GROWTH PLACE, LLC
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Dates
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Enumeration Date | 09/20/2019
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Last Update Date | 09/20/2019
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Provider Practice Location Address
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Address Line | 301 GRACELAND DR SE STE B
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City | ALBUQUERQUE
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State | NM
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Zip | 87108-2778
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Country | US
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Telephone | 575-740-1689
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Fax |
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Provider Business Mailing Address
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Address Line | 2813 ALVARADO DR NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87110-3229
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Country | US
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Telephone | 575-740-1689
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KASSANDRA WILLIAMS
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Credential | LMFT
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Telephone | 575-740-1689
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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