Provider Demographics
NPI:1598300972
Name:NORTHERN ROOTS THERAPY CENTER
Entity Type:Organization
Organization Name:NORTHERN ROOTS THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:VINSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, SAL, CFRC
Authorized Official - Phone:608-400-3818
Mailing Address - Street 1:2960 TRIVERTON PIKE DR
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53711-5896
Mailing Address - Country:US
Mailing Address - Phone:608-234-1224
Mailing Address - Fax:
Practice Address - Street 1:2960 TRIVERTON PIKE DR
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53711-5896
Practice Address - Country:US
Practice Address - Phone:608-234-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-09
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100191303Medicaid