Provider Demographics
NPI:1720663818
Name:VITAL ROOTS INC
Entity Type:Organization
Organization Name:VITAL ROOTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVENDER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:615-900-0984
Mailing Address - Street 1:6929 APPLE LN APT 2
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-0302
Mailing Address - Country:US
Mailing Address - Phone:833-337-6687
Mailing Address - Fax:
Practice Address - Street 1:6929 APPLE LN APT 2
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-0302
Practice Address - Country:US
Practice Address - Phone:833-337-6687
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty