Provider Demographics
NPI:1952837809
Name:GRAPEVINE CLINICAL LLC
Entity Type:Organization
Organization Name:GRAPEVINE CLINICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-369-0034
Mailing Address - Street 1:666 WALNUT ST STE 1610
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-3974
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:666 WALNUT ST STE 1610
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-3974
Practice Address - Country:US
Practice Address - Phone:515-360-0034
Practice Address - Fax:844-381-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0075721041C0700X
IA058151041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty