Provider Demographics
NPI:1063150290
Name:CROSS ROOTS COUNSELING LLC
Entity type:Organization
Organization Name:CROSS ROOTS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ VIETS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-273-2030
Mailing Address - Street 1:12231 ACADEMY RD NE SUITE 301
Mailing Address - Street 2:PMB 295
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 WELLESLEY DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-1443
Practice Address - Country:US
Practice Address - Phone:505-273-2030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty