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General NPI Number Information
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NPI Number | 1346822046
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Entity Type | Organization
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Legal Business Name | AUTHENTIC ROOTS THERAPY PLLC
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Dates
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Enumeration Date | 04/22/2021
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Last Update Date | 08/10/2021
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Provider Practice Location Address
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Address Line | 7077 NORTHLAND CIR N STE 330
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City | MINNEAPOLIS
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State | MN
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Zip | 55428-1567
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Country | US
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Telephone | 612-799-6652
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Fax |
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Provider Business Mailing Address
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Address Line | 11711 55TH ST NE
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City | ALBERTVILLE
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State | MN
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Zip | 55301-9745
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Country | US
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Telephone | 612-799-6652
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | AMANDA WIRTH
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Credential | LMFT
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Telephone | 612-799-6652
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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