Provider Demographics
NPI:1669251088
Name:GROW AND GLOW BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:GROW AND GLOW BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLAIR-TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-701-8161
Mailing Address - Street 1:11001 GOLDEN SILENCE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-2341
Mailing Address - Country:US
Mailing Address - Phone:305-494-2843
Mailing Address - Fax:
Practice Address - Street 1:11001 GOLDEN SILENCE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33579-2341
Practice Address - Country:US
Practice Address - Phone:305-494-2843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)