Provider Demographics
NPI:1699530097
Name:ROOTED WELL THERAPY
Entity type:Organization
Organization Name:ROOTED WELL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLETON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:406-209-4928
Mailing Address - Street 1:10542 PO BOX
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59719
Mailing Address - Country:US
Mailing Address - Phone:406-209-4928
Mailing Address - Fax:
Practice Address - Street 1:321 E MAIN ST STE 207
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-4731
Practice Address - Country:US
Practice Address - Phone:406-209-4928
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-15
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty