Healthcare Provider Details

I. General information

NPI: 1245846930
Provider Name (Legal Business Name): ROOTS TO THRIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 10TH AVE
CHARLESTON SC
29403-3601
US

IV. Provider business mailing address

1 10TH AVE
CHARLESTON SC
29403-3601
US

V. Phone/Fax

Practice location:
  • Phone: 843-790-5077
  • Fax:
Mailing address:
  • Phone: 843-790-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: KASEY ANNE OHAREN
Title or Position: OWNER
Credential:
Phone: 843-790-5077