Healthcare Provider Details

I. General information

NPI: 1033958475
Provider Name (Legal Business Name): ROOT & BLOOM THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2024
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1955 W HAMLIN RD STE 101
ROCHESTER HILLS MI
48309-3338
US

IV. Provider business mailing address

1955 W HAMLIN RD STE 101
ROCHESTER HILLS MI
48309-3338
US

V. Phone/Fax

Practice location:
  • Phone: 810-618-4374
  • Fax:
Mailing address:
  • Phone: 248-301-6455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JORDAN RILEY TASKER
Title or Position: CO-OWNER/COUNSELOR
Credential: LPC
Phone: 810-618-4374