=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073026498
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTS COUNSELING, PLLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2017
-----------------------------------------------------
Last Update Date | 11/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 180 W MICHIGAN AVE
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-1345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-392-1814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 HIGH ST
-----------------------------------------------------
City | MARSHALL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49068-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-392-1814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER/LICENSED COUNSELOR
-----------------------------------------------------
Name | ANNISSA J LEWIS
-----------------------------------------------------
Credential | MA,LPC, LBSW
-----------------------------------------------------
Telephone | 517-392-1814
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401009840
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------