Healthcare Provider Details

I. General information

NPI: 1023730314
Provider Name (Legal Business Name): ROOTED WILLOW THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2022
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330B S UNIVERSITY AVE
MOUNT PLEASANT MI
48858-2525
US

IV. Provider business mailing address

330B S UNIVERSITY AVE
MOUNT PLEASANT MI
48858-2525
US

V. Phone/Fax

Practice location:
  • Phone: 989-331-0045
  • Fax:
Mailing address:
  • Phone: 899-331-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHELBY CRISTINE CARSON
Title or Position: OWNER AND THERAPIST
Credential: LPC
Phone: 989-331-0045