=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932810868
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSEROOT COUNSELING AND CONSULTING, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2022
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6600 UNIVERSITY AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50324-1639
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-306-4590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 465 52ND PL
-----------------------------------------------------
City | WEST DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50265-2897
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-306-4590
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LISW CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | JENNIFER HAIDAR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 515-306-4590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------