Provider Demographics
NPI:1619552411
Name:ROOTED WELLNESS LLC
Entity Type:Organization
Organization Name:ROOTED WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLON-MAGA
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:857-204-7067
Mailing Address - Street 1:228 ALMONT ST
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-1487
Mailing Address - Country:US
Mailing Address - Phone:857-204-7067
Mailing Address - Fax:
Practice Address - Street 1:228 ALMONT ST
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-1487
Practice Address - Country:US
Practice Address - Phone:857-204-7067
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health