MEDICARE: GROW DEEP COUNSELING, LLC

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	101YP2500X	Professional Counselor	LPC003658	GA

General Provider Information

NPI Number	:	1851842553
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROW DEEP COUNSELING, LLC

Provider Business Mailing Address
First Line	:	PO BOX 491172
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30049-0020
Country	:	US
Telephone Number	:	770-331-9988
Fax Number	:	770-492-0301

Provider Business Practice Location Address
First Line	:	4830 RIVER GREEN PKWY
Second Line	:	SUITE 150
City	:	DULUTH
State	:	GA
Zip	:	30096-2505
Country	:	US
Telephone Number	:	770-331-9988
Fax Number	:	770-492-0301

Authorized Official
Title or Position	:	OWNER, THERAPIST
Name	:	KRISTIN RYAN
Credential	:	MS, LPC, CPCS
Telephone Number	:	770-331-9988

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	10/18/2016

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