=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568080323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MINDROOTS COUNSELING PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 S 1ST ST
-----------------------------------------------------
City | BENNETT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80102-7860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-622-4547
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4299 FLANDIN CT
-----------------------------------------------------
City | STRASBURG
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80136-8126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-421-6680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | PAMELLA ZACKERU
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 908-421-6680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------