Provider Demographics
NPI:1407396286
Name:INTENTIONAL GROWTH LLC
Entity Type:Organization
Organization Name:INTENTIONAL GROWTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARNIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:269-447-1211
Mailing Address - Street 1:5360 HOLIDAY TER
Mailing Address - Street 2:SUITE 18
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-2126
Mailing Address - Country:US
Mailing Address - Phone:269-447-1211
Mailing Address - Fax:
Practice Address - Street 1:5360 HOLIDAY TER
Practice Address - Street 2:SUITE 18
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-2126
Practice Address - Country:US
Practice Address - Phone:269-760-6236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012521101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty