Provider Demographics
NPI:1174264147
Name:ROOTED POTENTIAL LLC
Entity Type:Organization
Organization Name:ROOTED POTENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, OTR
Authorized Official - Phone:989-600-0794
Mailing Address - Street 1:2621 W WACKERLY ST STE B
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6994
Mailing Address - Country:US
Mailing Address - Phone:989-600-0794
Mailing Address - Fax:
Practice Address - Street 1:2621 W WACKERLY ST STE B
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6994
Practice Address - Country:US
Practice Address - Phone:989-600-0794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty