Provider Demographics
NPI:1417602632
Name:GROWTH AND WELLNESS MENTAL HEALTH COUNSELING AND SUPERVISION SERVICES
Entity Type:Organization
Organization Name:GROWTH AND WELLNESS MENTAL HEALTH COUNSELING AND SUPERVISION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TISHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-400-3743
Mailing Address - Street 1:2424 W BRANDON BLVD # 1182
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4717
Mailing Address - Country:US
Mailing Address - Phone:813-400-3743
Mailing Address - Fax:
Practice Address - Street 1:2429 ARBORWOOD DR
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-5738
Practice Address - Country:US
Practice Address - Phone:813-400-3743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health