Provider Demographics
NPI:1124526678
Name:ROOM TO GROW: THERAPY, SUPERVISION, CONSULTATION, PLLC
Entity type:Organization
Organization Name:ROOM TO GROW: THERAPY, SUPERVISION, CONSULTATION, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMFT
Authorized Official - Phone:940-536-3644
Mailing Address - Street 1:804 COMBS ST
Mailing Address - Street 2:
Mailing Address - City:QUANAH
Mailing Address - State:TX
Mailing Address - Zip Code:79252-4444
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8150 US HIGHWAY 287
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201-7152
Practice Address - Country:US
Practice Address - Phone:940-536-3644
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX201547106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty