MEDICARE: AUTHENTIC ROOTS COUNSELING PLLC

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	:	1568241149
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUTHENTIC ROOTS COUNSELING PLLC

Provider Business Mailing Address
First Line	:	1811 BOLIVAR ST
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76201-3044
Country	:	US
Telephone Number	:	940-553-0837
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 BOLIVAR ST
Second Line	:
City	:	DENTON
State	:	TX
Zip	:	76201-3044
Country	:	US
Telephone Number	:	940-553-0837
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ASHLEY WHITTED
Credential	:	LPC
Telephone Number	:	940-553-0837

Provider Enumeration Date	:	09/25/2023
Last Update Date	:	09/25/2023

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