=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972938967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROWTH & RECOVERY COUNSELING CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2013
-----------------------------------------------------
Last Update Date | 09/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7747 MITCHELL BLVD STE. B
-----------------------------------------------------
City | TRINITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-267-6247
-----------------------------------------------------
Fax | 888-878-0546
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7747 MITCHELL BLVD STE. B
-----------------------------------------------------
City | TRINITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34655-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-267-6247
-----------------------------------------------------
Fax | 888-878-0546
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, SENIOR THERAPIST
-----------------------------------------------------
Name | MRS. JOY DAVIS VINCENT
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 727-267-6247
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW9562
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------