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General NPI Number Information
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NPI Number | 1255478293
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Entity Type | Organization
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Legal Business Name | PERSONAL GROWTH CORPORATION
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 10/07/2010
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Provider Practice Location Address
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Address Line | 211 S WOODRUFF
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City | IDAHO FALLS
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State | ID
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Zip | 83401
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Country | US
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Telephone | 208-529-5548
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Fax | 208-529-5588
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Provider Business Mailing Address
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Address Line | 211 S WOODRUFF SUITE A4
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City | IDAHO FALLS
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State | ID
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Zip | 83401
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Country | US
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Telephone | 208-529-5548
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Fax | 208-529-5588
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. MICHAEL JON HARRIS
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Credential | MSW, PHD
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Telephone | 208-529-5548
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW420
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License Number State | ID
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