Provider Demographics
NPI:1558952184
Name:MINDFUL ROOTS COUNSELING, LLC
Entity Type:Organization
Organization Name:MINDFUL ROOTS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:MATALIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-599-4060
Mailing Address - Street 1:408 ELM ST
Mailing Address - Street 2:
Mailing Address - City:INDIANA
Mailing Address - State:PA
Mailing Address - Zip Code:15701-3131
Mailing Address - Country:US
Mailing Address - Phone:724-599-4060
Mailing Address - Fax:
Practice Address - Street 1:647 PHILADELPHIA ST STE 303
Practice Address - Street 2:
Practice Address - City:INDIANA
Practice Address - State:PA
Practice Address - Zip Code:15701-3923
Practice Address - Country:US
Practice Address - Phone:724-599-4060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty