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General NPI Number Information
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NPI Number | 1407220767
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Entity Type | Organization
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Legal Business Name | ROOTS AND WINGS COUNSELING WILLOW TREE WELLNESS LLC
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Dates
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Enumeration Date | 11/23/2015
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Last Update Date | 12/04/2015
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Provider Practice Location Address
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Address Line | 415 N HIGGINS AVE SUITE 122
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City | MISSOULA
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State | MT
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Zip | 59802-4557
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Country | US
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Telephone | 406-203-6937
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Fax | 844-965-9168
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Provider Business Mailing Address
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Address Line | 415 N HIGGINS AVE SUITE 122
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City | MISSOULA
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State | MT
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Zip | 59802-4557
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Country | US
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Telephone | 406-203-6937
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Fax | 844-965-9168
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Authorized Official
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Title or Position | OWNER
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Name | CYNTHIA RANDLES
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Credential | LCSW
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Telephone | 406-203-6937
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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 | 7134
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License Number State | MT
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