=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043126501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING ROOTS THERAPEUTICS, A PSYCHIATRIC NURSING INCORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2026
-----------------------------------------------------
Last Update Date | 08/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 632 W 11TH ST
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95376-3856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-509-4059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 632 W 11TH ST
-----------------------------------------------------
City | TRACY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95376-3856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-509-4059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP
-----------------------------------------------------
Name | SUPREET KAUR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 510-509-4059
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------