Provider Demographics
NPI:1265153761
Name:SIMPLY ROOTED SPEECH & WELLNESS LLC
Entity type:Organization
Organization Name:SIMPLY ROOTED SPEECH & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-573-2262
Mailing Address - Street 1:10144 E CINTRON DR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-9579
Mailing Address - Country:US
Mailing Address - Phone:480-573-2262
Mailing Address - Fax:480-573-2169
Practice Address - Street 1:1910 S STAPLEY DR STE 221
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6680
Practice Address - Country:US
Practice Address - Phone:480-573-2262
Practice Address - Fax:480-573-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-05
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ161344Medicaid