Healthcare Provider Details

I. General information

NPI: 1619850393
Provider Name (Legal Business Name): REROOTED: FAMILY AND TRAUMA RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2025
Last Update Date: 07/29/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 E RIVER PKWY
MINNEAPOLIS MN
55455-0369
US

IV. Provider business mailing address

7255 VINEWOOD LN N
MAPLE GROVE MN
55311-2816
US

V. Phone/Fax

Practice location:
  • Phone: 763-607-6420
  • Fax:
Mailing address:
  • Phone: 763-607-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MS. PEG KINDA
Title or Position: CONTRACTOR
Credential:
Phone: 612-306-8499