Provider Demographics
NPI:1073643482
Name:A GROWTH PLACE, INC.
Entity Type:Organization
Organization Name:A GROWTH PLACE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:T
Authorized Official - Last Name:SAMPLES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:770-506-9575
Mailing Address - Street 1:10 WILSON RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4433
Mailing Address - Country:US
Mailing Address - Phone:770-506-9575
Mailing Address - Fax:770-506-9369
Practice Address - Street 1:10 WILSON RD
Practice Address - Street 2:SUITE 1
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4433
Practice Address - Country:US
Practice Address - Phone:770-506-9575
Practice Address - Fax:770-506-9369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT000125106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA301563086AMedicaid