=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982290961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GROWTH ZONE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2020
-----------------------------------------------------
Last Update Date | 12/14/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1645 COMMERCE PARK DR
-----------------------------------------------------
City | CHELSEA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48118-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-780-9968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1645 COMMERCE PARK DR
-----------------------------------------------------
City | CHELSEA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48118-1451
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-780-9968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MRS. DORVIA A THOMAS-HILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 734-780-9968
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------