Provider Demographics
NPI:1407106743
Name:ROOTS, DIRK E (APRN - PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:DIRK
Middle Name:E
Last Name:ROOTS
Suffix:
Gender:M
Credentials:APRN - PMHNP-BC
Other - Prefix:
Other - First Name:DIRK
Other - Middle Name:ELWYN
Other - Last Name:ROOTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN, PMHNP-BC
Mailing Address - Street 1:409 N 7TH ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-4156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 N 7TH ST
Practice Address - Street 2:SUITE 3
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-4156
Practice Address - Country:US
Practice Address - Phone:318-322-8462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07063363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health