Provider Demographics
NPI:1013608900
Name:MENDING ROOTS THERAPY
Entity Type:Organization
Organization Name:MENDING ROOTS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KASSI
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:903-227-2418
Mailing Address - Street 1:1042 S IDLEWILD DR
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-8326
Mailing Address - Country:US
Mailing Address - Phone:903-227-2418
Mailing Address - Fax:
Practice Address - Street 1:1042 S IDLEWILD DR
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75090-8326
Practice Address - Country:US
Practice Address - Phone:903-227-2418
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty