Healthcare Provider Details

I. General information

NPI: 1194296897
Provider Name (Legal Business Name): ROOT THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2018
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1283 N 14TH AVE STE 101
BOZEMAN MT
59715-3270
US

IV. Provider business mailing address

2411 W MAIN ST STE 2
BOZEMAN MT
59718-3815
US

V. Phone/Fax

Practice location:
  • Phone: 406-219-5388
  • Fax:
Mailing address:
  • Phone: 406-219-5388
  • Fax: 406-219-5379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KEZIA PETERSON
Title or Position: OCCUPATIONAL THERAPIST/OWNER
Credential: OT
Phone: 406-219-5388