=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851448146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROWTH WORKS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 09/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 271 S MAIN STREET
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-455-4095
-----------------------------------------------------
Fax | 734-455-1254
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 271 S MAIN STREET
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-455-4095
-----------------------------------------------------
Fax | 734-455-1254
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MRS. DEANNA WHEELER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-216-6451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | 4301043592
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------