Healthcare Provider Details

I. General information

NPI: 1336964527
Provider Name (Legal Business Name): MINDFUL ROOTS WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S JACKSON ST STE 301
SEATTLE WA
98104-2872
US

IV. Provider business mailing address

5706 17TH AVE NW UNIT 17509
SEATTLE WA
98127-1650
US

V. Phone/Fax

Practice location:
  • Phone: 509-724-0152
  • Fax:
Mailing address:
  • Phone: 509-724-0152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMY HERSH
Title or Position: OWNER
Credential: MA, LMHC
Phone: 509-724-0152