Healthcare Provider Details

I. General information

NPI: 1588451181
Provider Name (Legal Business Name): FROM ROOTS TO WINGS BEHAVIORAL CONSULTING AND SUPERVISION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2025
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 GOLD HILL RD # 3104
FORT MILL SC
29708-7946
US

IV. Provider business mailing address

885 GOLD HILL RD # 3104
FORT MILL SC
29708-7946
US

V. Phone/Fax

Practice location:
  • Phone: 803-902-5943
  • Fax: 803-675-0443
Mailing address:
  • Phone: 803-902-5943
  • Fax: 803-675-0443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE M CLEMENTE
Title or Position: OWNER/BEHAVIOR ANALYST
Credential: MS, BCBA
Phone: 803-207-1695