Provider Demographics
NPI:1053479634
Name:FRESH ROOTS, INC.
Entity Type:Organization
Organization Name:FRESH ROOTS, INC.
Other - Org Name:FRESH ROOTS FAMILY COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELL
Authorized Official - Middle Name:CHRISTY
Authorized Official - Last Name:TYSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MA, LMFT, LPC
Authorized Official - Phone:479-986-8655
Mailing Address - Street 1:318 W POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-4559
Mailing Address - Country:US
Mailing Address - Phone:479-986-8655
Mailing Address - Fax:479-633-9398
Practice Address - Street 1:318 W POPLAR ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4559
Practice Address - Country:US
Practice Address - Phone:479-986-8655
Practice Address - Fax:479-633-9398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP9201002101YP2500X
ARM9710002106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty