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General NPI Number Information
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NPI Number | 1285253922
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Entity Type | Organization
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Legal Business Name | ROOTS COUNSELING
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Dates
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Enumeration Date | 04/13/2020
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Last Update Date | 04/13/2020
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Provider Practice Location Address
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Address Line | 24 E MAIN ST
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City | CORFU
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State | NY
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Zip | 14036-9601
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Country | US
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Telephone | 585-813-4075
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 57
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City | CORFU
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State | NY
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Zip | 14036-0057
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Country | US
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Telephone | 585-813-4075
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Fax |
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | MRS. VALERIE-LYNN A MUTKA
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Credential | LCSW-R
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Telephone | 585-813-4075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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