Healthcare Provider Details

I. General information

NPI: 1083459044
Provider Name (Legal Business Name): UPROOTED THERAPY A LICENSED CLINICAL SOCIAL WORKER CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2372 MORSE AVE STE 1135
IRVINE CA
92614-6234
US

IV. Provider business mailing address

2372 MORSE AVE STE 1135
IRVINE CA
92614-6234
US

V. Phone/Fax

Practice location:
  • Phone: 949-998-6033
  • Fax:
Mailing address:
  • Phone: 949-998-6033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: KAILA MORRISON
Title or Position: CEO, OWNER
Credential: LCSW, MSW
Phone: 949-998-6033