Provider Demographics
NPI:1629617568
Name:MOUNTAIN ROOT HEALING
Entity Type:Organization
Organization Name:MOUNTAIN ROOT HEALING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KATHREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:562-519-8492
Mailing Address - Street 1:122 W NICKLAUS AVE
Mailing Address - Street 2:
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901-2773
Mailing Address - Country:US
Mailing Address - Phone:562-519-8492
Mailing Address - Fax:
Practice Address - Street 1:307 1ST AVE E STE 15
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-4965
Practice Address - Country:US
Practice Address - Phone:562-519-8492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty