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General NPI Number Information
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NPI Number | 1295576676
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Entity Type | Organization
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Legal Business Name | RESILIENT ROOTS THERAPY LLC
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Dates
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Enumeration Date | 06/01/2024
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Last Update Date | 06/01/2024
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Provider Practice Location Address
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Address Line | 791 ENDERS RD
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City | HALIFAX
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State | PA
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Zip | 17032-9721
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Country | US
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Telephone | 717-599-2909
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Fax |
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Provider Business Mailing Address
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Address Line | 16 MATAMORAS RD
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City | HALIFAX
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State | PA
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Zip | 17032-9501
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Country | US
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Telephone | 814-470-3718
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Fax |
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Authorized Official
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Title or Position | OWNER/THERAPIST
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Name | JESSICA MARIE SIMMONS
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Credential | LCSW
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Telephone | 814-470-3718
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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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