Provider Demographics
NPI:1861849754
Name:THE ROOTS COUNSELING CENTER
Entity Type:Organization
Organization Name:THE ROOTS COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERILYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OBERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:575-297-0171
Mailing Address - Street 1:310 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-2834
Mailing Address - Country:US
Mailing Address - Phone:575-297-0171
Mailing Address - Fax:575-288-2806
Practice Address - Street 1:310 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-2834
Practice Address - Country:US
Practice Address - Phone:575-297-0171
Practice Address - Fax:575-288-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0180421101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM81985363Medicaid