Provider Demographics
NPI:1780208199
Name:ROOTED VITALITY HEALTH COLLABORATIVE A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:ROOTED VITALITY HEALTH COLLABORATIVE A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:559-221-2584
Mailing Address - Street 1:516 W SHAW AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-2515
Mailing Address - Country:US
Mailing Address - Phone:559-221-2584
Mailing Address - Fax:559-494-4831
Practice Address - Street 1:516 W SHAW AVE STE 200
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-2515
Practice Address - Country:US
Practice Address - Phone:559-221-2584
Practice Address - Fax:559-494-4831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty