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General NPI Number Information
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NPI Number | 1689494262
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Entity Type | Organization
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Legal Business Name | CONQUER ADDICTION PLLC
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Dates
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Enumeration Date | 10/16/2024
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Last Update Date | 10/16/2024
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Provider Practice Location Address
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Address Line | 809 W MAIN ST STE C
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City | MONROE
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State | WA
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Zip | 98272-2172
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Country | US
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Telephone | 206-552-0882
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Fax | 844-440-2147
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Provider Business Mailing Address
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Address Line | 809 W MAIN ST STE C
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City | MONROE
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State | WA
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Zip | 98272-2172
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Country | US
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Telephone | 206-552-0882
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Fax | 844-440-2147
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Authorized Official
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Title or Position | OWNER
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Name | JACOB ADAM GRILLO
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Credential | PA-C
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Telephone | 206-552-0882
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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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 | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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