Provider Demographics
NPI:1851155014
Name:SOUTHERN ROOTS THERAPEUTIC SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHERN ROOTS THERAPEUTIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:606-304-7994
Mailing Address - Street 1:74 FALIN LN
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-1791
Mailing Address - Country:US
Mailing Address - Phone:606-304-7994
Mailing Address - Fax:
Practice Address - Street 1:74 FALIN LN
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1791
Practice Address - Country:US
Practice Address - Phone:606-304-7994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-08
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty