MEDICARE: NEW 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1790311306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW ROOTS COUNSELING LLC

Provider Business Mailing Address
First Line	:	102 23RD AVE SW APT E203
Second Line	:
City	:	PUYALLUP
State	:	WA
Zip	:	98371-7888
Country	:	US
Telephone Number	:	253-249-1284
Fax Number	:

Provider Business Practice Location Address
First Line	:	7214 LINDEN AVE N
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98103-5112
Country	:	US
Telephone Number	:	253-249-1284
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS OWNER
Name	:	MS. SIMONE ANTOINETTE WALCOTT
Credential	:	LMFT
Telephone Number	:	253-249-1284

Provider Enumeration Date	:	03/14/2020
Last Update Date	:	03/14/2020

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