Healthcare Provider Details

I. General information

NPI: 1669889283
Provider Name (Legal Business Name): ROOTS COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2014
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4485 N OAKLAND AVE
SHOREWOOD WI
53211-1611
US

IV. Provider business mailing address

4485 N OAKLAND AVE
SHOREWOOD WI
53211-1611
US

V. Phone/Fax

Practice location:
  • Phone: 414-273-8484
  • Fax: 414-446-3317
Mailing address:
  • Phone: 414-273-8484
  • Fax: 414-446-3317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TREVOR NETTLES
Title or Position: ADMINISTRATOR
Credential:
Phone: 414-273-8484