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General NPI Number Information
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NPI Number | 1588575377
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Entity Type | Organization
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Legal Business Name | SACRED ROOTS HEALING & SUPPORT CENTER
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Dates
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Enumeration Date | 09/14/2026
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Last Update Date | 09/14/2026
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Provider Practice Location Address
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Address Line | 679 BATCHELOR ST # A
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City | TOMS RIVER
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State | NJ
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Zip | 08753-6885
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Country | US
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Telephone | 908-839-5507
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Fax |
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Provider Business Mailing Address
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Address Line | 729 FORECASTLE AVE
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City | BEACHWOOD
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State | NJ
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Zip | 08722-2515
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Country | US
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Telephone | 908-839-5507
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MARY PREVITE
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Credential | LPC, NCC
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Telephone | 908-839-5507
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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