MEDICARE: ROOTWISE MENTAL WELLNESS

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1417789702
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTWISE MENTAL WELLNESS

Provider Business Mailing Address
First Line	:	6417 PENN AVE S STE 7-1381
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55423-1186
Country	:	US
Telephone Number	:	641-780-2070
Fax Number	:

Provider Business Practice Location Address
First Line	:	4048 COLUMBUS AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3111
Country	:	US
Telephone Number	:	641-780-2070
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LEAH CHALLBERG
Credential	:
Telephone Number	:	641-780-2070

Provider Enumeration Date	:	08/15/2024
Last Update Date	:	08/15/2024

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Directions to “ROOTWISE MENTAL WELLNESS ” Practice Location

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