Provider Demographics
NPI:1790311306
Name:NEW ROOTS COUNSELING LLC
Entity Type:Organization
Organization Name:NEW ROOTS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SIMONE
Authorized Official - Middle Name:ANTOINETTE
Authorized Official - Last Name:WALCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:253-249-1284
Mailing Address - Street 1:102 23RD AVE SW APT E203
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-7888
Mailing Address - Country:US
Mailing Address - Phone:253-249-1284
Mailing Address - Fax:
Practice Address - Street 1:7214 LINDEN AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-5112
Practice Address - Country:US
Practice Address - Phone:253-249-1284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)