MEDICARE: ROOTS COUNSELING 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1669889283
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROOTS COUNSELING SERVICES, LLC

Provider Business Mailing Address
First Line	:	4485 N OAKLAND AVE
Second Line	:
City	:	SHOREWOOD
State	:	WI
Zip	:	53211-1611
Country	:	US
Telephone Number	:	414-273-8484
Fax Number	:	414-446-3317

Provider Business Practice Location Address
First Line	:	4485 N OAKLAND AVE
Second Line	:
City	:	SHOREWOOD
State	:	WI
Zip	:	53211-1611
Country	:	US
Telephone Number	:	414-273-8484
Fax Number	:	414-446-3317

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	TREVOR NETTLES
Credential	:
Telephone Number	:	414-273-8484

Provider Enumeration Date	:	07/15/2014
Last Update Date	:	01/22/2025

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