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General NPI Number Information
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NPI Number | 1013608900
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Entity Type | Organization
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Legal Business Name | MENDING ROOTS THERAPY
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Dates
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Enumeration Date | 05/19/2023
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Last Update Date | 05/19/2023
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Provider Practice Location Address
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Address Line | 1042 S IDLEWILD DR
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City | SHERMAN
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State | TX
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Zip | 75090-8326
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Country | US
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Telephone | 903-227-2418
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Fax |
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Provider Business Mailing Address
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Address Line | 1042 S IDLEWILD DR
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City | SHERMAN
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State | TX
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Zip | 75090-8326
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Country | US
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Telephone | 903-227-2418
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | KASSI LIGHTFOOT
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Credential | LCSW
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Telephone | 903-227-2418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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