MEDICARE: ROOTED LIFE COUNSELING CENTER, LLC

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	:	1205488335
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTED LIFE COUNSELING CENTER, LLC

Provider Business Mailing Address
First Line	:	9067 W POST RD UNIT A2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2440
Country	:	US
Telephone Number	:	702-820-8843
Fax Number	:

Provider Business Practice Location Address
First Line	:	9067 W POST RD UNIT A2
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-2440
Country	:	US
Telephone Number	:	702-820-8843
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KLOVER KALLAS
Credential	:	LMFCT
Telephone Number	:	702-820-8843

Provider Enumeration Date	:	07/09/2019
Last Update Date	:	07/09/2019

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