Healthcare Provider Details

I. General information

NPI: 1568483725
Provider Name (Legal Business Name): MARLA M ROOT LMHP/CPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 D ST SUITE 2
FAIRBURY NE
68352-2318
US

IV. Provider business mailing address

510 D ST SUITE 2
FAIRBURY NE
68352-2318
US

V. Phone/Fax

Practice location:
  • Phone: 402-729-6979
  • Fax: 402-729-4094
Mailing address:
  • Phone: 402-729-6979
  • Fax: 402-729-4094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2918
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: