Healthcare Provider Details

I. General information

NPI: 1972521755
Provider Name (Legal Business Name): MICHAEL VINCENT ROOTS LCSW, CAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INSTALLATION MANAGEMENT AGENCY-E ATTN:SFIM-EU-HR (SAIC-ASACS) UNIT 29353 BOX 200
APO AE
09014
US

IV. Provider business mailing address

PSC3 BOX 1624
APO AE
09021
US

V. Phone/Fax

Practice location:
  • Phone: 00496221163912
  • Fax:
Mailing address:
  • Phone: 00496371915800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4089
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number011768L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: