Provider Demographics
NPI:1700699071
Name:FRESH THERAPEUTIC GROUP
Entity type:Organization
Organization Name:FRESH THERAPEUTIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:ILESANMI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-530-6628
Mailing Address - Street 1:11042 STONE LEGEND DR
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-0071
Mailing Address - Country:US
Mailing Address - Phone:410-530-6628
Mailing Address - Fax:
Practice Address - Street 1:9210 CRESTVIEW DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77078-4002
Practice Address - Country:US
Practice Address - Phone:832-514-7925
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-29
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health