Provider Demographics
NPI:1326837808
Name:GROW WILD THERAPY CENTER, LLC
Entity type:Organization
Organization Name:GROW WILD THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES-HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:757-635-2869
Mailing Address - Street 1:6863 SE HENRY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6508
Mailing Address - Country:US
Mailing Address - Phone:757-635-2869
Mailing Address - Fax:
Practice Address - Street 1:6863 SE HENRY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-6508
Practice Address - Country:US
Practice Address - Phone:757-635-2869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty