=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841079720
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROWTH AND EMPOWERMENT MENTAL HEALTHCARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/28/2023
-----------------------------------------------------
Last Update Date | 10/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1223 E MAIN ST STE 2029
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43205-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-301-7310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1223 E MAIN ST
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43205-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-301-7310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | VINCENT INGRAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-301-7310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------