Provider Demographics
NPI:1891505939
Name:RESILIENT ROOTS THERAPY
Entity type:Organization
Organization Name:RESILIENT ROOTS THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LCSW
Authorized Official - Prefix:
Authorized Official - First Name:SAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:207-550-1043
Mailing Address - Street 1:744 ROOSEVELT TRL STE 207
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5281
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:744 ROOSEVELT TRL STE 207
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5281
Practice Address - Country:US
Practice Address - Phone:207-550-1043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty