Provider Demographics
NPI:1922695758
Name:RESTORED ROOTS COUNSELING & WELLNESS
Entity Type:Organization
Organization Name:RESTORED ROOTS COUNSELING & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADIEUX
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:419-605-8722
Mailing Address - Street 1:4938 STATE ROUTE 111
Mailing Address - Street 2:
Mailing Address - City:ANTWERP
Mailing Address - State:OH
Mailing Address - Zip Code:45813-9724
Mailing Address - Country:US
Mailing Address - Phone:419-605-8722
Mailing Address - Fax:
Practice Address - Street 1:4938 STATE ROUTE 111
Practice Address - Street 2:
Practice Address - City:ANTWERP
Practice Address - State:OH
Practice Address - Zip Code:45813-9724
Practice Address - Country:US
Practice Address - Phone:419-605-8722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty