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General NPI Number Information
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NPI Number | 1922695758
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Entity Type | Organization
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Legal Business Name | RESTORED ROOTS COUNSELING & WELLNESS
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Dates
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Enumeration Date | 12/28/2020
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Last Update Date | 12/28/2020
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Provider Practice Location Address
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Address Line | 4938 STATE ROUTE 111
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City | ANTWERP
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State | OH
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Zip | 45813-9724
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Country | US
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Telephone | 419-605-8722
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Fax |
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Provider Business Mailing Address
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Address Line | 4938 STATE ROUTE 111
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City | ANTWERP
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State | OH
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Zip | 45813-9724
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Country | US
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Telephone | 419-605-8722
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICIAN
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Name | KAYLA GLADIEUX
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Credential | LISW
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Telephone | 419-605-8722
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family 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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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