Provider Demographics
NPI:1821206541
Name:THE GREEN HOUSE CENTER FOR GROWTH AND LEARNING
Entity Type:Organization
Organization Name:THE GREEN HOUSE CENTER FOR GROWTH AND LEARNING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:COLLETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWSONLOVELESS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-785-1169
Mailing Address - Street 1:135 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2207
Mailing Address - Country:US
Mailing Address - Phone:801-785-1169
Mailing Address - Fax:801-785-1154
Practice Address - Street 1:135 W CENTER ST
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2207
Practice Address - Country:US
Practice Address - Phone:801-785-1169
Practice Address - Fax:801-785-1154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348753-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT788007788047Medicaid