Provider Demographics
NPI:1871083691
Name:SECOND GROWTH COUNSELING LLC
Entity type:Organization
Organization Name:SECOND GROWTH COUNSELING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:CARLYN
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:618-339-7497
Mailing Address - Street 1:PO BOX 90309
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-0309
Mailing Address - Country:US
Mailing Address - Phone:503-549-4714
Mailing Address - Fax:
Practice Address - Street 1:959 SE DIVISION ST STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4672
Practice Address - Country:US
Practice Address - Phone:503-549-4714
Practice Address - Fax:503-506-0411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC3909101YP2500X
1041C0700X
ORR4154106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty