Provider Demographics
NPI:1972270080
Name:COLLABORATIVE ROOTS COUNSELING, LLC
Entity Type:Organization
Organization Name:COLLABORATIVE ROOTS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KIENZLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LCPC, NCC
Authorized Official - Phone:847-920-8882
Mailing Address - Street 1:413 BEDFORD LN
Mailing Address - Street 2:
Mailing Address - City:VOLO
Mailing Address - State:IL
Mailing Address - Zip Code:60073-8182
Mailing Address - Country:US
Mailing Address - Phone:847-504-9382
Mailing Address - Fax:
Practice Address - Street 1:413 BEDFORD LN
Practice Address - Street 2:
Practice Address - City:VOLO
Practice Address - State:IL
Practice Address - Zip Code:60073-8182
Practice Address - Country:US
Practice Address - Phone:847-504-9382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-26
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty