Healthcare Provider Details

I. General information

NPI: 1518762764
Provider Name (Legal Business Name): HEALING ROOTS PSYCHOTHERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BIG BEAVER RD
TROY MI
48083-1208
US

IV. Provider business mailing address

200 E BIG BEAVER RD
TROY MI
48083-1208
US

V. Phone/Fax

Practice location:
  • Phone: 586-718-2670
  • Fax:
Mailing address:
  • Phone: 586-718-2670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LEA DICKINSON
Title or Position: MANAGER
Credential: MA
Phone: 586-718-2670