=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619850393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REROOTED: FAMILY AND TRAUMA RECOVERY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2025
-----------------------------------------------------
Last Update Date | 07/29/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 E RIVER PKWY
-----------------------------------------------------
City | MINNEAPOLIS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55455-0369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-607-6420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7255 VINEWOOD LN N
-----------------------------------------------------
City | MAPLE GROVE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55311-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-607-6420
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTOR
-----------------------------------------------------
Name | MS. PEG KINDA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 612-306-8499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------