Healthcare Provider Details

I. General information

NPI: 1528894573
Provider Name (Legal Business Name): WELL ROOTED COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4251 SHAMROCK DR
VENICE FL
34293-5661
US

IV. Provider business mailing address

4251 SHAMROCK DR
VENICE FL
34293-5661
US

V. Phone/Fax

Practice location:
  • Phone: 719-985-7668
  • Fax:
Mailing address:
  • Phone: 719-985-7668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAURA ANN BELLAMY
Title or Position: LICENSED MENTAL HEALTH COUNSELOR
Credential: MA LMHC NCC
Phone: 719-985-7668