Provider Demographics
NPI:1457127847
Name:ROOT INTEGRATIVE HEALTH
Entity Type:Organization
Organization Name:ROOT INTEGRATIVE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:SHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:470-709-0679
Mailing Address - Street 1:480 JOINTER AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30079-1516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8735 DUNWOODY PL # 8114
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-2995
Practice Address - Country:US
Practice Address - Phone:470-709-0679
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-28
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801203997OtherNPPES