Healthcare Provider Details

I. General information

NPI: 1225977911
Provider Name (Legal Business Name): NEURO-ROOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2026
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 S 35TH ST
MANITOWOC WI
54220-5413
US

IV. Provider business mailing address

1338 WESTWOOD LN
MANITOWOC WI
54220-1602
US

V. Phone/Fax

Practice location:
  • Phone: 920-690-3955
  • Fax:
Mailing address:
  • Phone: 920-690-3955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER KALISTA
Title or Position: OWNER
Credential: LPC
Phone: 920-242-0520