Healthcare Provider Details

I. General information

NPI: 1619829603
Provider Name (Legal Business Name): RAISED AND ROOTED THERAPEUTIC COLLECTIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2026
Last Update Date: 02/11/2026
Certification Date: 02/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14800 FARMINGTON RD STE 109
LIVONIA MI
48154-5464
US

IV. Provider business mailing address

14800 FARMINGTON RD STE 109
LIVONIA MI
48154-5464
US

V. Phone/Fax

Practice location:
  • Phone: 734-776-8380
  • Fax:
Mailing address:
  • Phone: 734-776-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANNON N MATHISON
Title or Position: PSYCHOTHERAPIST
Credential: MS, LLP
Phone: 734-776-8380