MEDICARE: INTEGRATED ROOTS THERAPY 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1568202380
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED ROOTS THERAPY LLC

Provider Business Mailing Address
First Line	:	4810 ILENE LN
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-1425
Country	:	US
Telephone Number	:	262-685-1918
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 ATWOOD AVE STE 217
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53704-5382
Country	:	US
Telephone Number	:	608-352-6211
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JENNIFER LEE SMITH
Credential	:	LCSW
Telephone Number	:	262-685-1918

Provider Enumeration Date	:	05/29/2024
Last Update Date	:	05/29/2024

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