=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821407743
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROOTED CONNECTIONS COUNSELING, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2014
-----------------------------------------------------
Last Update Date | 09/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5100 N RAVENSWOOD SUITE 235
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-417-6342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5100 N RAVENSWOOD SUITE 235
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-417-6342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHELLE LYNN CUTLER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 773-417-6342
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 071006457
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------