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General NPI Number Information
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NPI Number | 1346162229
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Entity Type | Organization
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Legal Business Name | ROOTS NORTH WINGS SOUTH LLC
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Dates
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Enumeration Date | 07/29/2026
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Last Update Date | 07/29/2026
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Provider Practice Location Address
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Address Line | 715 ISLE VERDE DR
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City | MYRTLE BEACH
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State | SC
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Zip | 29579-7168
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Country | US
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Telephone | 631-599-6177
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Fax |
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Provider Business Mailing Address
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Address Line | 715 ISLE VERDE DR
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City | MYRTLE BEACH
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State | SC
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Zip | 29579-7168
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Country | US
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Telephone | 631-599-6177
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | STEPHANIE DURSO
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Credential | LCSW, LISW-CP
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Telephone | 631-599-6177
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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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