Healthcare Provider Details

I. General information

NPI: 1346162229
Provider Name (Legal Business Name): ROOTS NORTH WINGS SOUTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 ISLE VERDE DR
MYRTLE BEACH SC
29579-7168
US

IV. Provider business mailing address

715 ISLE VERDE DR
MYRTLE BEACH SC
29579-7168
US

V. Phone/Fax

Practice location:
  • Phone: 631-599-6177
  • Fax:
Mailing address:
  • Phone: 631-599-6177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE DURSO
Title or Position: OWNER
Credential: LCSW, LISW-CP
Phone: 631-599-6177