Provider Demographics
NPI:1285253922
Name:ROOTS COUNSELING
Entity type:Organization
Organization Name:ROOTS COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VALERIE-LYNN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MUTKA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW-R
Authorized Official - Phone:585-813-4075
Mailing Address - Street 1:PO BOX 57
Mailing Address - Street 2:
Mailing Address - City:CORFU
Mailing Address - State:NY
Mailing Address - Zip Code:14036-0057
Mailing Address - Country:US
Mailing Address - Phone:585-813-4075
Mailing Address - Fax:
Practice Address - Street 1:24 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CORFU
Practice Address - State:NY
Practice Address - Zip Code:14036-9601
Practice Address - Country:US
Practice Address - Phone:585-813-4075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1962596718Medicaid