Provider Demographics
NPI:1972352177
Name:REFLECTIVE ROOTS PSYCHOTHERAPY & HEALING, LLC
Entity type:Organization
Organization Name:REFLECTIVE ROOTS PSYCHOTHERAPY & HEALING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOTHERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LICSW, LCSW
Authorized Official - Phone:715-495-5486
Mailing Address - Street 1:808 CARMICHAEL ROAD
Mailing Address - Street 2:PMB #241
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016
Mailing Address - Country:US
Mailing Address - Phone:157-201-4563
Mailing Address - Fax:
Practice Address - Street 1:1186 121ST ST
Practice Address - Street 2:
Practice Address - City:ROBERTS
Practice Address - State:WI
Practice Address - Zip Code:54023-8538
Practice Address - Country:US
Practice Address - Phone:715-495-5486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-18
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty