Provider Demographics
NPI:1538651070
Name:PRIMAL ROOTS MIDWIFERY LLC
Entity Type:Organization
Organization Name:PRIMAL ROOTS MIDWIFERY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED PROFESSIONAL MIDWIFE
Authorized Official - Prefix:
Authorized Official - First Name:SERA
Authorized Official - Middle Name:L
Authorized Official - Last Name:GADBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:CPM
Authorized Official - Phone:860-230-5344
Mailing Address - Street 1:566 DEVOTION RD
Mailing Address - Street 2:
Mailing Address - City:BALTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06330-2306
Mailing Address - Country:US
Mailing Address - Phone:860-230-5344
Mailing Address - Fax:860-455-4214
Practice Address - Street 1:14 VINE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1431
Practice Address - Country:US
Practice Address - Phone:860-230-5344
Practice Address - Fax:860-455-4214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1804176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty