Provider Demographics
NPI:1700303716
Name:ROOTED PSYCHOTHERAPY; PLLC
Entity Type:Organization
Organization Name:ROOTED PSYCHOTHERAPY; PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:CMHC
Authorized Official - Phone:801-683-1160
Mailing Address - Street 1:10246 S SAMUEL HOLT DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-8840
Mailing Address - Country:US
Mailing Address - Phone:801-440-7177
Mailing Address - Fax:
Practice Address - Street 1:12441 S 900 E # 170
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9807
Practice Address - Country:US
Practice Address - Phone:801-683-1160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8020295-6004261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health