Healthcare Provider Details

I. General information

NPI: 1194642546
Provider Name (Legal Business Name): HEALING ROOTS MENTAL HEALTH FAMILY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4873 PALM COAST PKWY NW UNIT 2
PALM COAST FL
32137-3669
US

IV. Provider business mailing address

4873 PALM COAST PKWY NW UNIT 2
PALM COAST FL
32137-3669
US

V. Phone/Fax

Practice location:
  • Phone: 301-310-1325
  • Fax:
Mailing address:
  • Phone: 301-310-1325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. FERNANDO SAMUEL SOSA SANTOS
Title or Position: OWNER
Credential: LMHC
Phone: 301-310-1325