Healthcare Provider Details

I. General information

NPI: 1730764069
Provider Name (Legal Business Name): ROOTS COUNSELING & CONSULTATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

856 E 8TH ST STE 1
TRAVERSE CITY MI
49686-2784
US

IV. Provider business mailing address

10220 COSTER RD SW
FIFE LAKE MI
49633-8218
US

V. Phone/Fax

Practice location:
  • Phone: 248-882-1338
  • Fax:
Mailing address:
  • Phone: 248-882-1338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: ALLISON RENEE WILSON
Title or Position: OWNER/MENTAL HEALTH THERAPIST
Credential: MS, LPC
Phone: 231-577-6676