Provider Demographics
NPI:1003664947
Name:RADICAL ROOTS PSYCHOTHERAPY, A LICENSED CLINICAL SOCIAL WORKER, PC
Entity type:Organization
Organization Name:RADICAL ROOTS PSYCHOTHERAPY, A LICENSED CLINICAL SOCIAL WORKER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHIAS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:626-833-1106
Mailing Address - Street 1:440 N BARRANCA AVE # 1918
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91723-1722
Mailing Address - Country:US
Mailing Address - Phone:609-694-1872
Mailing Address - Fax:
Practice Address - Street 1:65 E LATIMER AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1205
Practice Address - Country:US
Practice Address - Phone:626-833-1106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty