Provider Demographics
NPI:1902376163
Name:HEALING ROOTS COUNSELING LLC
Entity Type:Organization
Organization Name:HEALING ROOTS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:678-948-5783
Mailing Address - Street 1:3773 BUTTERFIELD DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-6989
Mailing Address - Country:US
Mailing Address - Phone:678-770-7577
Mailing Address - Fax:
Practice Address - Street 1:1690 STONE VILLAGE LN NW STE 601B
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7777
Practice Address - Country:US
Practice Address - Phone:678-948-5783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty