Healthcare Provider Details

I. General information

NPI: 1306758305
Provider Name (Legal Business Name): MINDFUL ROOTS PSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 BURLINGAME RD
CHARLTON MA
01507-5204
US

IV. Provider business mailing address

120 CHARLTON RD STE 2
STURBRIDGE MA
01566-1564
US

V. Phone/Fax

Practice location:
  • Phone: 508-581-3965
  • Fax:
Mailing address:
  • Phone: 508-581-3965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: RYAN DAVIDSON
Title or Position: OWNER
Credential: PHD
Phone: 508-581-3956