Provider Demographics
NPI:1417783903
Name:GROW WELL BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:GROW WELL BEHAVIORAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-488-8002
Mailing Address - Street 1:5840 S MEMORIAL DR STE 212
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9081
Mailing Address - Country:US
Mailing Address - Phone:918-644-1858
Mailing Address - Fax:
Practice Address - Street 1:5840 S MEMORIAL DR STE 212
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9081
Practice Address - Country:US
Practice Address - Phone:918-488-8002
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROW WELL HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health