MEDICARE: INSIGHTFUL ROOTS FAMILY THERAPY INC

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	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1053157172
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSIGHTFUL ROOTS FAMILY THERAPY INC

Provider Business Mailing Address
First Line	:	455 UNIVERSITY AVE STE 215
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-6580
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 UNIVERSITY AVE STE 215
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-6580
Country	:	US
Telephone Number	:	916-209-0348
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MARISA RONQUILLO
Credential	:
Telephone Number	:	209-451-8623

Provider Enumeration Date	:	07/08/2024
Last Update Date	:	07/08/2024

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