=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336917889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAPROOT THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2023
-----------------------------------------------------
Last Update Date | 12/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 LEXINGTON AVE STE 2A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-446-3365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 LEXINGTON AVE STE 2A
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10016-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 374-446-3365
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | ERIN IWANUSA
-----------------------------------------------------
Credential | LCSW, CDWF, PMH-C
-----------------------------------------------------
Telephone | 347-446-3365
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------