Healthcare Provider Details

I. General information

NPI: 1477782670
Provider Name (Legal Business Name): ROOTS & WINGS INDIVIDUAL AND FAMILY COUNSELING ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2009
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8356 ALLISON AVE SUITE B2
LA MESA CA
91941-3857
US

IV. Provider business mailing address

7918 EL CAJON BLVD SUITE N #307
LA MESA CA
91941-3710
US

V. Phone/Fax

Practice location:
  • Phone: 619-737-7721
  • Fax:
Mailing address:
  • Phone: 619-737-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCS23510
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFCC45648
License Number StateCA

VIII. Authorized Official

Name: MS. AISHA D POPE
Title or Position: PRESIDENT
Credential: LCSW
Phone: 619-737-7721