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General NPI Number Information
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NPI Number | 1760056659
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Entity Type | Organization
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Legal Business Name | GREEN ROOT THERAPY
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Dates
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Enumeration Date | 05/17/2021
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Last Update Date | 01/07/2022
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Provider Practice Location Address
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Address Line | 1323 BUTTERFIELD RD STE 114
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-5620
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Country | US
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Telephone | 708-778-3259
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Fax |
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Provider Business Mailing Address
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Address Line | 1323 BUTTERFIELD RD STE 114
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City | DOWNERS GROVE
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State | IL
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Zip | 60515-5620
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Country | US
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Telephone | 708-778-3259
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Fax | 815-206-8045
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Authorized Official
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Title or Position | PRESIDENT
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Name | KRISTINA LEE STAACK
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Credential | LCPC
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Telephone | 708-778-3259
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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