1790580264 NPI number — ROOTS TO ROSES PSYCHOTHERAPY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790580264 NPI number — ROOTS TO ROSES PSYCHOTHERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROOTS TO ROSES PSYCHOTHERAPY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790580264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
45 PERRY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHESTER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07930-3604
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-529-0355
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
45 PERRY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESTER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07930-3604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-529-0355
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2025

Additional Information

Authorized Official

Authorized Official Last Name:
KUDLESS
Authorized Official First Name:
ANASTASIA
Authorized Official Middle Name:
KATHERINE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
732-529-0355

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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