1215379086 NPI number — GRASSROOTS THERAPY GROUP LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215379086 NPI number — GRASSROOTS THERAPY GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRASSROOTS THERAPY GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215379086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/05/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1212 N WASHINGTON ST STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99201-2401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-279-8838
Provider Business Mailing Address Fax Number:
509-267-2717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1212 N WASHINGTON ST STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99201-2401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-279-8838
Provider Business Practice Location Address Fax Number:
509-267-2717
Provider Enumeration Date:
07/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
EASTEP
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
CO-OWNER
Authorized Official Telephone Number:
509-279-8838

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2041978 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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