MEDICARE: ROOTS PSYCHOLOGICAL SERVICES, 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	251S00000X	Community/Behavioral Health Agency	LP5231	MN

General Provider Information

NPI Number	:	1285062133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTS PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	3101 MAJOR AVE N
Second Line	:
City	:	GOLDEN VALLEY
State	:	MN
Zip	:	55422-3138
Country	:	US
Telephone Number	:	763-464-4575
Fax Number	:

Provider Business Practice Location Address
First Line	:	7026 E FISH LAKE RD
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-2832
Country	:	US
Telephone Number	:	763-777-1105
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLAUDIA DAML
Credential	:	PSYD, LP
Telephone Number	:	763-464-4575

Provider Enumeration Date	:	10/30/2013
Last Update Date	:	10/30/2013

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