Healthcare Provider Details

I. General information

NPI: 1922695758
Provider Name (Legal Business Name): RESTORED ROOTS COUNSELING & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4938 STATE ROUTE 111
ANTWERP OH
45813-9724
US

IV. Provider business mailing address

4938 STATE ROUTE 111
ANTWERP OH
45813-9724
US

V. Phone/Fax

Practice location:
  • Phone: 419-605-8722
  • Fax:
Mailing address:
  • Phone: 419-605-8722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: KAYLA GLADIEUX
Title or Position: OWNER/CLINICIAN
Credential: LISW
Phone: 419-605-8722