MEDICARE: PRAIRIE ROOTS COUNSELING, 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	:	1699637462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRAIRIE ROOTS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	3620 MEADOW LN
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-4028
Country	:	US
Telephone Number	:	316-282-5787
Fax Number	:

Provider Business Practice Location Address
First Line	:	3620 MEADOW LN
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67218-4028
Country	:	US
Telephone Number	:	316-282-5787
Fax Number	:

Authorized Official
Title or Position	:	OWNER / MANAGING MEMBER
Name	:	KRISTEN ANN PELTZER
Credential	:	LMSW, THERAPIST
Telephone Number	:	316-282-5787

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/02/2025

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