Healthcare Provider Details

I. General information

NPI: 1972466928
Provider Name (Legal Business Name): MINDFUL ROOTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2025
Last Update Date: 12/06/2025
Certification Date: 12/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

706 N MAIN ST
BUFFALO WY
82834-1746
US

IV. Provider business mailing address

99 HARMONY ST
BUFFALO WY
82834-2460
US

V. Phone/Fax

Practice location:
  • Phone: 307-620-2933
  • Fax:
Mailing address:
  • Phone: 307-620-2932
  • 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: TEMPE MCSTAY
Title or Position: OWNER/MENTAL HEALTH COUNSELOR
Credential: LCSW
Phone: 307-620-2932