MEDICARE: GROWTH SPACE, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1457918526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROWTH SPACE, PLLC

Provider Business Mailing Address
First Line	:	8601 N BLACK CANYON HWY STE 103OFC10
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4109
Country	:	US
Telephone Number	:	602-845-0707
Fax Number	:	602-296-0398

Provider Business Practice Location Address
First Line	:	8601 N BLACK CANYON HWY STE 103OFC10
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85021-4109
Country	:	US
Telephone Number	:	602-845-0707
Fax Number	:	602-296-0398

Authorized Official
Title or Position	:	MENTAL HEALTH COUNSELOR/ CLINICIAN
Name	:	KATHRYN MCCLEARN
Credential	:	LPC
Telephone Number	:	602-845-0707

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	12/22/2020

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