Healthcare Provider Details

I. General information

NPI: 1861981839
Provider Name (Legal Business Name): ROOT TO RISE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2018
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1498 LONG LAKE DR
BRIGHTON MI
48114-9637
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 810-279-0450
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801092427
License Number StateMI

VIII. Authorized Official

Name: MARY BETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9797