Provider Demographics
NPI:1144065202
Name:GRACEFUL GROWTH CLINIC LLC
Entity type:Organization
Organization Name:GRACEFUL GROWTH CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LCMHC/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MIRIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCMHC
Authorized Official - Phone:385-409-0363
Mailing Address - Street 1:657 E 980 N
Mailing Address - Street 2:
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-9833
Mailing Address - Country:US
Mailing Address - Phone:801-928-8980
Mailing Address - Fax:
Practice Address - Street 1:66 W VINE ST STE 6
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-2185
Practice Address - Country:US
Practice Address - Phone:801-928-8980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-28
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty