Healthcare Provider Details

I. General information

NPI: 1821914995
Provider Name (Legal Business Name): ROOT & RETURN THERAPY, A LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3079 HARRISON AVE 12 UNIT 118
SOUTH LAKE TAHOE CA
96150
US

IV. Provider business mailing address

PO BOX 9683
SOUTH LAKE TAHOE CA
96158-2683
US

V. Phone/Fax

Practice location:
  • Phone: 530-447-0253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KSENIA USTINOVA
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 530-447-0253