Provider Demographics
NPI:1043700800
Name:ROOTS THERAPY & CONSULTING LLC
Entity Type:Organization
Organization Name:ROOTS THERAPY & CONSULTING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:JONG
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:612-234-1072
Mailing Address - Street 1:3343 15TH AVE S APT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-2269
Mailing Address - Country:US
Mailing Address - Phone:612-234-1072
Mailing Address - Fax:
Practice Address - Street 1:2920 BRYANT AVE S STE 112
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2332
Practice Address - Country:US
Practice Address - Phone:612-234-1072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)