Healthcare Provider Details

I. General information

NPI: 1780503441
Provider Name (Legal Business Name): ROOTED MIND & BODY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N1547 OVERLOOK DR
GENOA CITY WI
53128-1592
US

IV. Provider business mailing address

N1547 OVERLOOK DR
GENOA CITY WI
53128-1592
US

V. Phone/Fax

Practice location:
  • Phone: 815-575-9559
  • Fax:
Mailing address:
  • Phone: 815-575-9559
  • 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: MR. MATTHEW FETROW
Title or Position: OWNER
Credential: LCSW
Phone: 815-575-9559