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General NPI Number Information
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NPI Number | 1114726981
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Entity Type | Organization
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Legal Business Name | ROOTED VINES COUNSELING LCSW PLLC
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Dates
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Enumeration Date | 03/12/2025
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Last Update Date | 03/12/2025
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Provider Practice Location Address
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Address Line | 57 PERSHING DR
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City | SCOTIA
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State | NY
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Zip | 12302-2917
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Country | US
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Telephone | 518-810-1791
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Fax |
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Provider Business Mailing Address
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Address Line | 57 PERSHING DR
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City | SCOTIA
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State | NY
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Zip | 12302-2917
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Country | US
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Telephone | 518-810-1791
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Fax |
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Authorized Official
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Title or Position | MEMBER-MANAGER
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Name | SHANNON SCHALLERT
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Credential | LCSW-R
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Telephone | 518-810-1791
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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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