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General NPI Number Information
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NPI Number | 1699551101
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Entity Type | Organization
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Legal Business Name | NOURISHED ROOTS THERAPY SERVICES
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Dates
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Enumeration Date | 08/31/2023
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Last Update Date | 07/31/2025
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Provider Practice Location Address
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Address Line | 1271 OLD US 1 HWY UNIT B
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-6308
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Country | US
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Telephone | 910-310-9479
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Fax |
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Provider Business Mailing Address
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Address Line | 1271 OLD US 1 HWY UNIT B
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City | SOUTHERN PINES
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State | NC
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Zip | 28387-6308
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Country | US
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Telephone | 910-310-9479
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Fax |
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Authorized Official
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Title or Position | SPEECH- LANGUAGE PATHOLOGIST
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Name | JENA LEIGH SOUTHERLAND
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Credential | MS, CCC-SLP, CLC
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Telephone | 910-310-9479
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 174N00000X
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Taxonomy Name | Lactation Consultant (Non-RN)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number |
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License Number State |
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