Provider Demographics
NPI:1861007817
Name:ROOTED COUNSELING LLC
Entity Type:Organization
Organization Name:ROOTED COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:630-935-5662
Mailing Address - Street 1:221 CAROL LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1694
Mailing Address - Country:US
Mailing Address - Phone:630-935-5662
Mailing Address - Fax:
Practice Address - Street 1:13242 S ROUTE 59 STE 102A
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-5438
Practice Address - Country:US
Practice Address - Phone:331-465-9588
Practice Address - Fax:331-625-6448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-15
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149015311OtherCLINICAL SOCIAL WORKER LICENSE NUMBER