Healthcare Provider Details

I. General information

NPI: 1215663554
Provider Name (Legal Business Name): STRONG ROOTS THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 07/06/2023
Certification Date: 07/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E WESTPOINT DR STE 210
WASILLA AK
99654-7183
US

IV. Provider business mailing address

PO BOX 1905
PALMER AK
99645-1905
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-0486
  • Fax:
Mailing address:
  • Phone: 912-674-0417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1707635
Identifier TypeMEDICAID
Identifier StateAK
Identifier Issuer

VIII. Authorized Official

Name: TIFFANY DAWN LEMERY
Title or Position: CEO
Credential: LCSW, CATP, CDC II,
Phone: 912-674-0417