Healthcare Provider Details

I. General information

NPI: 1376117218
Provider Name (Legal Business Name): ROOTS & WINGS WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2021
Last Update Date: 05/15/2021
Certification Date: 05/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1947 SILVERWEED WAY
OVIEDO FL
32765-4621
US

IV. Provider business mailing address

1947 SILVERWEED WAY
OVIEDO FL
32765-4621
US

V. Phone/Fax

Practice location:
  • Phone: 352-398-2136
  • Fax:
Mailing address:
  • Phone: 352-398-2136
  • 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: DR. TAMARA WALDEN
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 352-398-2136