Healthcare Provider Details

I. General information

NPI: 1376464438
Provider Name (Legal Business Name): ROOTED MIND PSYCHIATRIC SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 PRESIDENTIAL BLVD STE W3
BALA CYNWYD PA
19004-1205
US

IV. Provider business mailing address

191 PRESIDENTIAL BLVD STE W3
BALA CYNWYD PA
19004-1205
US

V. Phone/Fax

Practice location:
  • Phone: 215-550-1614
  • Fax:
Mailing address:
  • Phone: 215-550-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MELISSA BRUBAKER
Title or Position: OWNER
Credential: CRNP
Phone: 215-550-1614