Provider Demographics
NPI:1417567983
Name:COMMUNITY ROOTS COUNSELING, LLC
Entity Type:Organization
Organization Name:COMMUNITY ROOTS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST AND FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JES
Authorized Official - Middle Name:
Authorized Official - Last Name:DIMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LICSW, LSSW
Authorized Official - Phone:503-583-2121
Mailing Address - Street 1:PO BOX 5312
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-0312
Mailing Address - Country:US
Mailing Address - Phone:503-583-2121
Mailing Address - Fax:855-855-4872
Practice Address - Street 1:494 STATE ST STE 270
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3647
Practice Address - Country:US
Practice Address - Phone:503-583-2121
Practice Address - Fax:855-855-4872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-08
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500688776Medicaid