Provider Demographics
NPI:1104575430
Name:WILDLY ROOTED COUNSELING LLC
Entity type:Organization
Organization Name:WILDLY ROOTED COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:540-578-3691
Mailing Address - Street 1:304 W SPOTSWOOD TRAIL
Mailing Address - Street 2:SUITE D
Mailing Address - City:ELKTON
Mailing Address - State:VA
Mailing Address - Zip Code:22827
Mailing Address - Country:US
Mailing Address - Phone:540-578-3691
Mailing Address - Fax:540-578-3691
Practice Address - Street 1:304 W SPOTSWOOD TRAIL
Practice Address - Street 2:SUITE D
Practice Address - City:ELKTON
Practice Address - State:VA
Practice Address - Zip Code:22827
Practice Address - Country:US
Practice Address - Phone:540-578-3691
Practice Address - Fax:540-578-3691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty