=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255001624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONQUER ADDICTION PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2021
-----------------------------------------------------
Last Update Date | 10/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 W MAIN ST STE C
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98272-2172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-552-0882
-----------------------------------------------------
Fax | 844-440-2147
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 W MAIN ST STE C
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98272-2172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-552-0882
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JACOB GRILLO
-----------------------------------------------------
Credential | MBA, PA-C
-----------------------------------------------------
Telephone | 425-387-1863
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------