Healthcare Provider Details

I. General information

NPI: 1861007817
Provider Name (Legal Business Name): ROOTED COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 12/17/2020
Certification Date: 12/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13242 S ROUTE 59 STE 102A
PLAINFIELD IL
60585-5438
US

IV. Provider business mailing address

221 CAROL LN
BOLINGBROOK IL
60440-1694
US

V. Phone/Fax

Practice location:
  • Phone: 331-465-9588
  • Fax: 331-625-6448
Mailing address:
  • Phone: 630-935-5662
  • 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 State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier149015311
Identifier TypeOTHER
Identifier StateIL
Identifier IssuerCLINICAL SOCIAL WORKER LICENSE NUMBER

VIII. Authorized Official

Name: JESSICA PARKS
Title or Position: OWNER, CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 630-935-5662