Provider Demographics
NPI:1013653187
Name:SOULFULLY ROOTED WELLNESS PLLC
Entity Type:Organization
Organization Name:SOULFULLY ROOTED WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-333-1596
Mailing Address - Street 1:2100 ALAMO RD STE T
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2738
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 ALAMO RD STE T
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2738
Practice Address - Country:US
Practice Address - Phone:469-333-1596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty