Provider Demographics
NPI:1336588607
Name:GROWING POTENTIAL SERVICES:THERAPEUTIC AND BEHAVIORAL SOLUTIONS, PC
Entity Type:Organization
Organization Name:GROWING POTENTIAL SERVICES:THERAPEUTIC AND BEHAVIORAL SOLUTIONS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCY
Authorized Official - Middle Name:
Authorized Official - Last Name:TALICEO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LMHC
Authorized Official - Phone:860-698-6077
Mailing Address - Street 1:25 HIGH ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3410
Mailing Address - Country:US
Mailing Address - Phone:860-698-6077
Mailing Address - Fax:860-698-6631
Practice Address - Street 1:25 HIGH ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082
Practice Address - Country:US
Practice Address - Phone:606-986-0778
Practice Address - Fax:860-698-6631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2378251S00000X
MA8146251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008045179Medicaid