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General NPI Number Information
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NPI Number | 1265153761
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Entity Type | Organization
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Legal Business Name | SIMPLY ROOTED SPEECH & WELLNESS LLC
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Dates
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Enumeration Date | 09/05/2022
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Last Update Date | 07/09/2024
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Provider Practice Location Address
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Address Line | 1910 S STAPLEY DR STE 221
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City | MESA
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State | AZ
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Zip | 85204-6680
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Country | US
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Telephone | 480-573-2262
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Fax | 480-573-2169
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Provider Business Mailing Address
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Address Line | 10144 E CINTRON DR
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City | MESA
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State | AZ
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Zip | 85212-9579
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Country | US
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Telephone | 480-573-2262
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Fax | 480-573-2169
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Authorized Official
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Title or Position | ADMINISTRATOR, OWNER
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Name | HEATHER MAIN
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Credential |
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Telephone | 480-573-2262
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133N00000X
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Taxonomy Name | Nutritionist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2355S0801X
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Taxonomy Name | Speech-Language Assistant
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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