Healthcare Provider Details

I. General information

NPI: 1467920942
Provider Name (Legal Business Name): ROOTS AND WINGS COUNSELING STUDIO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2018
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1851 SILVERSTONE DR
FOREST GROVE OR
97116-3227
US

IV. Provider business mailing address

1851 SILVERSTONE DR
FOREST GROVE OR
97116-3227
US

V. Phone/Fax

Practice location:
  • Phone: 512-766-5501
  • Fax:
Mailing address:
  • Phone: 512-766-5501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LYNSEY LOMELI
Title or Position: LCSW
Credential: LCSW
Phone: 503-209-5731