Healthcare Provider Details

I. General information

NPI: 1285416685
Provider Name (Legal Business Name): NOURISHING ROOTS THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2023
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

486 E 42ND ST
LOVELAND CO
80538-2354
US

IV. Provider business mailing address

486 E 42ND ST
LOVELAND CO
80538-2354
US

V. Phone/Fax

Practice location:
  • Phone: 925-303-0515
  • Fax:
Mailing address:
  • Phone: 925-303-0515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number StateNULL

VIII. Authorized Official

Name: JADYN ELIZABETH LEWIS
Title or Position: CEO, SLP
Credential: M.A., CCC-SLP
Phone: 925-303-0515