Provider Demographics
NPI:1831880426
Name:ROOTS SUBSTANCE ABUSE COUNSELING LLC
Entity type:Organization
Organization Name:ROOTS SUBSTANCE ABUSE COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VANTUYL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-522-2582
Mailing Address - Street 1:201 PIERCE ST STE 110
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51101-1479
Mailing Address - Country:US
Mailing Address - Phone:712-522-2582
Mailing Address - Fax:712-522-2586
Practice Address - Street 1:201 PIERCE ST STE 110
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1479
Practice Address - Country:US
Practice Address - Phone:712-522-2582
Practice Address - Fax:712-522-2586
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty