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General NPI Number Information
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NPI Number | 1982471553
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Entity Type | Organization
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Legal Business Name | WILD ROOTS PSYCHOTHERAPY & FAMILY COUNSELING, INC.
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Dates
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Enumeration Date | 12/05/2023
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Last Update Date | 12/05/2023
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Provider Practice Location Address
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Address Line | 35 HARRINGTON AVE UNIT 1316
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City | SHREWSBURY
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State | MA
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Zip | 01545-5277
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Country | US
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Telephone | 951-460-0005
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Fax |
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Provider Business Mailing Address
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Address Line | 945 MORNING STAR DR
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City | SONORA
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State | CA
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Zip | 95370-9249
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | ANDIE TRAN
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Credential |
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Telephone | 951-460-0005
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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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 | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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