Healthcare Provider Details

I. General information

NPI: 1073311023
Provider Name (Legal Business Name): ROOT & BRANCH WELLNESS COLLABORATIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 03/05/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 CONSTITUTION ST
CANTON MI
48188-6719
US

IV. Provider business mailing address

266 CONSTITUTION ST
CANTON MI
48188-6719
US

V. Phone/Fax

Practice location:
  • Phone: 734-743-2286
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ELISE MCNULTY
Title or Position: MEMBER
Credential: LMSW
Phone: 734-743-2286