Healthcare Provider Details

I. General information

NPI: 1164341988
Provider Name (Legal Business Name): ROOT AND RIDGE COUNSELING AND CONSULTING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 SHIELDS RD STE B
DALTON GA
30720-5064
US

IV. Provider business mailing address

975 POPLAR SPRINGS RD NW
DALTON GA
30720-7091
US

V. Phone/Fax

Practice location:
  • Phone: 706-217-8711
  • Fax:
Mailing address:
  • Phone: 706-250-0804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. BRUCE L BROADRICK JR.
Title or Position: OWNER
Credential: PHARM D, LPC
Phone: 706-250-0804