Healthcare Provider Details

I. General information

NPI: 1114669850
Provider Name (Legal Business Name): ROOTS AND RAYS CREATIVE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10421 S CHURCH ST
CHICAGO IL
60643-2940
US

IV. Provider business mailing address

10421 S CHURCH ST
CHICAGO IL
60643-2940
US

V. Phone/Fax

Practice location:
  • Phone: 708-572-3801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: ROBERT FOREMAN
Title or Position: CREDENTAILING
Credential:
Phone: 630-313-0069