MEDICARE: HEALING ROOTS CENTRE, L.L.L.P

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1023754637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALING ROOTS CENTRE, L.L.L.P

Provider Business Mailing Address
First Line	:	4533 WALNUT CREEK DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-4540
Country	:	US
Telephone Number	:	859-705-8967
Fax Number	:

Provider Business Practice Location Address
First Line	:	4533 WALNUT CREEK DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-4540
Country	:	US
Telephone Number	:	859-705-8967
Fax Number	:

Authorized Official
Title or Position	:	GENERAL PARTNER
Name	:	KENDRA MULDER
Credential	:	DSW
Telephone Number	:	859-705-8967

Provider Enumeration Date	:	05/06/2022
Last Update Date	:	05/23/2023

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