=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205793908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTED THERAPY COLLECTIVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2026
-----------------------------------------------------
Last Update Date | 01/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 GLEN RD UNIT 3
-----------------------------------------------------
City | JAMAICA PLAIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-210-8275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20 GLEN RD UNIT 3
-----------------------------------------------------
City | JAMAICA PLAIN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02130-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-210-8275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | CATHERINE MCGEOUGH
-----------------------------------------------------
Credential | LICSW
-----------------------------------------------------
Telephone | 207-210-8275
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------