Basic Information
| Provider Information | |||||||||
| NPI: | 1275813222 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GROWING MINDS LEARNING CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 MURFREESBORO PIKE STE 702 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372172679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155691314 | ||||||||
| FaxNumber: | 6155775654 | ||||||||
| Practice Location | |||||||||
| Address1: | 1711 DESTINY LN STE 107 | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421041067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155691314 | ||||||||
| FaxNumber: | 6155775654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 05/07/2020 | ||||||||
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| AuthorizedOfficialLastName: | ORITZ | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR, MANAGED CARE CONTRACTING | ||||||||
| AuthorizedOfficialTelephone: | 6155691314 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 251C00000X | N | Agencies | Day Training, Developmentally Disabled Services | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 7100174590 | 01 | KY | SCL WAIVER | OTHER | 7100215710 | 05 | KY | MEDICAID |