MEDICARE: WISE & ROOTED COUNSELING AND THERAPY

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	251C00000X	Developmentally Disabled Services Day Training Agency
2	251B00000X	Case Management Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295462174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE & ROOTED COUNSELING AND THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 2968
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77704-2968
Country	:	US
Telephone Number	:	409-877-1961
Fax Number	:

Provider Business Practice Location Address
First Line	:	1050 S 11TH ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-4739
Country	:	US
Telephone Number	:	409-202-3107
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM ADMINISTRATOR
Name	:	MRS. SHUKIA N RELFORD
Credential	:	MA, LCDC-I
Telephone Number	:	409-273-4172

Provider Enumeration Date	:	08/02/2022
Last Update Date	:	03/27/2023

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