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General NPI Number Information
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NPI Number | 1326837808
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Entity Type | Organization
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Legal Business Name | GROW WILD THERAPY CENTER, LLC
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Dates
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Enumeration Date | 05/02/2025
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Last Update Date | 05/02/2025
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Provider Practice Location Address
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Address Line | 6863 SE HENRY ST
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City | PORTLAND
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State | OR
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Zip | 97206-6508
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Country | US
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Telephone | 757-635-2869
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Fax |
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Provider Business Mailing Address
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Address Line | 6863 SE HENRY ST
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City | PORTLAND
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State | OR
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Zip | 97206-6508
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Country | US
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Telephone | 757-635-2869
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MRS. AMANDA HUGHES-HUERTA
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Credential | LPC
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Telephone | 757-635-2869
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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