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General NPI Number Information
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NPI Number | 1306758305
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Entity Type | Organization
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Legal Business Name | MINDFUL ROOTS PSYCHOTHERAPY, LLC
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Dates
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Enumeration Date | 09/22/2026
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Last Update Date | 09/22/2026
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Provider Practice Location Address
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Address Line | 131 BURLINGAME RD
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City | CHARLTON
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State | MA
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Zip | 01507-5204
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Country | US
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Telephone | 508-581-3965
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Fax |
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Provider Business Mailing Address
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Address Line | 120 CHARLTON RD STE 2
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City | STURBRIDGE
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State | MA
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Zip | 01566-1564
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Country | US
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Telephone | 508-581-3965
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | RYAN DAVIDSON
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Credential | PHD
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Telephone | 508-581-3956
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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