Provider Demographics
NPI:1790495364
Name:BUILT FOR GROWTH LLC
Entity Type:Organization
Organization Name:BUILT FOR GROWTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:718-913-0234
Mailing Address - Street 1:84 FRONT ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORT JERVIS
Mailing Address - State:NY
Mailing Address - Zip Code:12771-2415
Mailing Address - Country:US
Mailing Address - Phone:718-913-0234
Mailing Address - Fax:
Practice Address - Street 1:84 FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2415
Practice Address - Country:US
Practice Address - Phone:718-913-0234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY757683Medicaid