Healthcare Provider Details

I. General information

NPI: 1598696577
Provider Name (Legal Business Name): RESILIENT ROOTS THERAPY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6555 AMBROSIA DR
SAN DIEGO CA
92124-3226
US

IV. Provider business mailing address

1050 UNIVERSITY AVE STE 107
SAN DIEGO CA
92103-3359
US

V. Phone/Fax

Practice location:
  • Phone: 213-537-2874
  • Fax:
Mailing address:
  • Phone: 213-537-2874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ASHANTI MIRANDA
Title or Position: OWNER/OPERATOR
Credential: LCSW
Phone: 213-537-2874