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General NPI Number Information
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NPI Number | 1912775065
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Entity Type | Organization
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Legal Business Name | ROOTED IN CHANGE, LLC
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Dates
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Enumeration Date | 12/18/2023
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Last Update Date | 12/18/2023
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Provider Practice Location Address
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Address Line | 422 W SPRUCE ST STOP C
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City | MISSOULA
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State | MT
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Zip | 59802-4141
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Country | US
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Telephone | 858-868-0364
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 16592
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City | MISSOULA
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State | MT
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Zip | 59808-6592
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Country | US
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Telephone | 858-868-0364
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Fax |
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | DR. ANGELA PETERSEN
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Credential | PH.D.
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Telephone | 858-868-0364
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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