Healthcare Provider Details

I. General information

NPI: 1205077187
Provider Name (Legal Business Name): KATIE MARIE HEIDEN ROOTES PH.D., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 LINDELL BLVD STE 1100
SAINT LOUIS MO
63108-3412
US

IV. Provider business mailing address

3700 LINDELL BLVD STE 1100
SAINT LOUIS MO
63108-3412
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8196
  • Fax:
Mailing address:
  • Phone: 314-977-8196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2011037729
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: