=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255966131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTS AND BRANCHES COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2020
-----------------------------------------------------
Last Update Date | 03/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 NW GREELEY AVE
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97703-2911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-241-2252
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 61336 STARDRIFT DR
-----------------------------------------------------
City | BEND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97702-2051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-804-2295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | KARISSA L VIEBECK
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 541-241-2252
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------