Healthcare Provider Details

I. General information

NPI: 1023735321
Provider Name (Legal Business Name): ROOTED RECOVERY AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5418 N EAGLE RD STE 160
BOISE ID
83713-0100
US

IV. Provider business mailing address

85835 ALLBRITAIN LN
EUGENE OR
97405-8403
US

V. Phone/Fax

Practice location:
  • Phone: 541-844-3577
  • Fax:
Mailing address:
  • Phone: 541-972-1891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KATHERINE LYNN FRASER
Title or Position: EXECUTIVE DIRECTOR
Credential: MS, LPC
Phone: 888-455-1642