=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194530071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTED BEHAVIORAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 137 PETERBOROUGH ST APT 27
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02215-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-959-2860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 137 PETERBOROUGH ST APT 27
-----------------------------------------------------
City | BOSTON
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02215-4212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-959-2860
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | SHAADEE SAMIMY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 617-942-1339
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------