Healthcare Provider Details

I. General information

NPI: 1407784598
Provider Name (Legal Business Name): ROOTED SELF COUNSELING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45571 RUISLIP MANOR WAY
STERLING VA
20166-9239
US

IV. Provider business mailing address

45571 RUISLIP MANOR WAY
STERLING VA
20166-9239
US

V. Phone/Fax

Practice location:
  • Phone: 571-926-6453
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MAXINE IIDA
Title or Position: OWNER
Credential:
Phone: 571-926-6453