=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780216820
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOLID ROOTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2020
-----------------------------------------------------
Last Update Date | 02/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 CONTINENTAL PL
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | --
-----------------------------------------------------
Fax | 248-856-9384
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26149 VALHALLA DR
-----------------------------------------------------
City | FARMINGTON HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48331-3782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GINA CREAN
-----------------------------------------------------
Credential | DSW, LCSW
-----------------------------------------------------
Telephone | --
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------