Provider Demographics
NPI:1811719040
Name:ROOTED THERAPY AND WELLNESS, PLLC
Entity type:Organization
Organization Name:ROOTED THERAPY AND WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE GENDUSA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LICSW
Authorized Official - Phone:509-434-6386
Mailing Address - Street 1:3546 E GREYSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-6860
Mailing Address - Country:US
Mailing Address - Phone:509-434-6386
Mailing Address - Fax:
Practice Address - Street 1:3546 E GREYSTONE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72764-6860
Practice Address - Country:US
Practice Address - Phone:509-434-6386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty