=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790335271
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERATHRIVE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2019
-----------------------------------------------------
Last Update Date | 07/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 STRADA CIR STE 102
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-3219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-899-5904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1516 HAMPTON DR
-----------------------------------------------------
City | MANSFIELD
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76063-7915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-899-5904
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/MANAGER
-----------------------------------------------------
Name | SUZANNE BENITES
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 817-899-5904
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------