Provider Demographics
NPI:1740980085
Name:GROW DEFINED THERAPY LLC
Entity type:Organization
Organization Name:GROW DEFINED THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RIVER
Authorized Official - Middle Name:
Authorized Official - Last Name:GROW
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:360-320-6099
Mailing Address - Street 1:9450 SW GEMINI DR
Mailing Address - Street 2:PMB 28613
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5305 RIVER RD N STE B
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-5324
Practice Address - Country:US
Practice Address - Phone:360-320-6099
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500810951Medicaid
OR500814140Medicaid