Provider Demographics
NPI:1205595477
Name:ACACIA ROOTS COUNSELING LLC
Entity type:Organization
Organization Name:ACACIA ROOTS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:CHRISTINA
Authorized Official - Last Name:CORNEJO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:708-232-3550
Mailing Address - Street 1:84 E BURLINGTON ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60546-2118
Mailing Address - Country:US
Mailing Address - Phone:708-232-3550
Mailing Address - Fax:
Practice Address - Street 1:84 E BURLINGTON ST UNIT 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2118
Practice Address - Country:US
Practice Address - Phone:708-232-3550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-14
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health