=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386776763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROWING PLACES THERAPY SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2100 WESTFALIAN TRL
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78732-1967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-587-5671
-----------------------------------------------------
Fax | 512-535-6786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2100 WESTFALIAN TRL
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78732-1967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-587-5671
-----------------------------------------------------
Fax | 512-535-6786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MISS DOUG C LEVINE
-----------------------------------------------------
Credential | MSPT
-----------------------------------------------------
Telephone | 512-587-5671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1118164
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------