Healthcare Provider Details

I. General information

NPI: 1124508734
Provider Name (Legal Business Name): CONNECTED ROOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 38TH ST STE 100E
BOULDER CO
80301-2624
US

IV. Provider business mailing address

1650 38TH ST STE 100E
BOULDER CO
80301-2624
US

V. Phone/Fax

Practice location:
  • Phone: 720-593-1383
  • Fax:
Mailing address:
  • Phone: 720-593-1383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09925299
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: LAUREN ANDRE
Title or Position: CO-OWNER
Credential: LCSW
Phone: 720-593-1383