Healthcare Provider Details

I. General information

NPI: 1396522967
Provider Name (Legal Business Name): ROOTS PSYCHOLOGICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 ATLANTIC AVE STE 102
LONG BEACH CA
90807-3535
US

IV. Provider business mailing address

3939 ATLANTIC AVE STE 102
LONG BEACH CA
90807-3535
US

V. Phone/Fax

Practice location:
  • Phone: 562-471-7710
  • Fax:
Mailing address:
  • Phone: 562-471-7710
  • 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 Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DIANA KANG
Title or Position: PRESIDENT
Credential: PSY.D
Phone: 562-471-7710