Provider Demographics
NPI:1346822046
Name:AUTHENTIC ROOTS THERAPY PLLC
Entity Type:Organization
Organization Name:AUTHENTIC ROOTS THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-799-6652
Mailing Address - Street 1:11711 55TH ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-9745
Mailing Address - Country:US
Mailing Address - Phone:612-799-6652
Mailing Address - Fax:
Practice Address - Street 1:7077 NORTHLAND CIR N STE 330
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55428-1567
Practice Address - Country:US
Practice Address - Phone:612-799-6652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-22
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7416210Medicaid