Provider Demographics
NPI:1255478293
Name:PERSONAL GROWTH CORPORATION
Entity Type:Organization
Organization Name:PERSONAL GROWTH CORPORATION
Other - Org Name:PERSONAL GROWTH CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JON
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, PHD
Authorized Official - Phone:208-529-5548
Mailing Address - Street 1:211 S WOODRUFF
Mailing Address - Street 2:SUITE A4
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-529-5548
Mailing Address - Fax:208-529-5588
Practice Address - Street 1:211 S WOODRUFF
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401
Practice Address - Country:US
Practice Address - Phone:208-529-5548
Practice Address - Fax:208-529-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW4201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty