Provider Demographics
NPI:1912775065
Name:ROOTED IN CHANGE, LLC
Entity Type:Organization
Organization Name:ROOTED IN CHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:858-868-0364
Mailing Address - Street 1:PO BOX 16592
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59808-6592
Mailing Address - Country:US
Mailing Address - Phone:858-868-0364
Mailing Address - Fax:
Practice Address - Street 1:422 W SPRUCE ST STOP C
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59802-4141
Practice Address - Country:US
Practice Address - Phone:858-868-0364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health