Provider Demographics
NPI:1790335271
Name:THERATHRIVE LLC
Entity Type:Organization
Organization Name:THERATHRIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BENITES
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:817-899-5904
Mailing Address - Street 1:1516 HAMPTON DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7915
Mailing Address - Country:US
Mailing Address - Phone:817-899-5904
Mailing Address - Fax:
Practice Address - Street 1:601 STRADA CIR STE 102
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3219
Practice Address - Country:US
Practice Address - Phone:817-899-5904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-16
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health