=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356118400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROW OR GO THERAPY SOLUTIONS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2023
-----------------------------------------------------
Last Update Date | 12/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1854 E PERRY ST STE 900
-----------------------------------------------------
City | PORT CLINTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43452-1586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-359-5110
-----------------------------------------------------
Fax | 419-359-5114
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1854 E PERRY ST STE 900
-----------------------------------------------------
City | PORT CLINTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43452-1586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-359-5110
-----------------------------------------------------
Fax | 419-359-5114
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | ANGELA HARRIS
-----------------------------------------------------
Credential | LISW-S
-----------------------------------------------------
Telephone | 419-573-9163
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------