Healthcare Provider Details

I. General information

NPI: 1851044903
Provider Name (Legal Business Name): ROOTED EMPOWERMENT COLLECTIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2022
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 CENTER COURT DR STE 107
COVINA CA
91724-3681
US

IV. Provider business mailing address

1338 CENTER COURT DR STE 107
COVINA CA
91724-3681
US

V. Phone/Fax

Practice location:
  • Phone: 626-275-8185
  • Fax:
Mailing address:
  • Phone: 626-275-8185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOAN MENDOZA
Title or Position: OWNER
Credential: LCSW
Phone: 323-533-3837