Healthcare Provider Details

I. General information

NPI: 1780303685
Provider Name (Legal Business Name): PACIFIC ROOTS MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 08/24/2022
Certification Date: 08/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19125 N CREEK PKWY STE 120
BOTHELL WA
98011-8000
US

IV. Provider business mailing address

19125 N CREEK PKWY STE 120
BOTHELL WA
98011-8000
US

V. Phone/Fax

Practice location:
  • Phone: 425-954-6796
  • Fax:
Mailing address:
  • Phone: 425-954-6796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier604923091
Identifier TypeOTHER
Identifier StateWA
Identifier IssuerSECRETARY OF STATE ISSUED UBI

VIII. Authorized Official

Name: MELISSA COLEEN MEJIAS
Title or Position: OWNER/THERAPIST
Credential: LICSW
Phone: 425-954-6796