Healthcare Provider Details

I. General information

NPI: 1720663818
Provider Name (Legal Business Name): VITAL ROOTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

6929 APPLE LN APT 2
CARBONDALE IL
62902-0302
US

IV. Provider business mailing address

6929 APPLE LN APT 2
CARBONDALE IL
62902-0302
US

V. Phone/Fax

Practice location:
  • Phone: 833-337-6687
  • Fax:
Mailing address:
  • Phone: 833-337-6687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: LEE CAVENDER
Title or Position: OWNER AND COUNSELOR
Credential: LCSW
Phone: 615-900-0984