Provider Demographics
NPI:1073160537
Name:ROOTS & WINGS THERAPY LLC
Entity Type:Organization
Organization Name:ROOTS & WINGS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BARBER
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC & ART THERAPIST
Authorized Official - Phone:773-930-0994
Mailing Address - Street 1:115 E 1ST ST STE 120
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3023
Mailing Address - Country:US
Mailing Address - Phone:773-930-0994
Mailing Address - Fax:
Practice Address - Street 1:115 E 1ST ST STE 120
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3023
Practice Address - Country:US
Practice Address - Phone:773-930-0994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1073963963OtherNPI
IL1992201479OtherNPI
IL1336792514OtherNPI