Healthcare Provider Details

I. General information

NPI: 1487316808
Provider Name (Legal Business Name): CONNECTED ROOTS YOUTH COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 03/28/2022
Certification Date: 03/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ASHLEY PARK BLVD APT 2014
NEWNAN GA
30263-6419
US

IV. Provider business mailing address

300 ASHLEY PARK BLVD APT 2014
NEWNAN GA
30263-6419
US

V. Phone/Fax

Practice location:
  • Phone: 740-807-1506
  • Fax: 678-306-8663
Mailing address:
  • Phone: 917-474-3083
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. STACEY BRISTOW
Title or Position: OWNER
Credential: BS
Phone: 740-807-1506