1821914995 NPI number — ROOT & RETURN THERAPY, A LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION

Table of content: (NPI 1821914995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821914995 NPI number — ROOT & RETURN THERAPY, A LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROOT & RETURN THERAPY, A LICENSED CLINICAL SOCIAL WORKER PROFESSIONAL CORPORATION
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:
1821914995
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9683
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH LAKE TAHOE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96158-2683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3079 HARRISON AVE 12
Provider Second Line Business Practice Location Address:
UNIT 118
Provider Business Practice Location Address City Name:
SOUTH LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-447-0253
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2026

Additional Information

Authorized Official

Authorized Official Last Name:
USTINOVA
Authorized Official First Name:
KSENIA
Authorized Official Middle Name:
Authorized Official Title or Position:
LICENSED CLINICAL SOCIAL WORKER
Authorized Official Telephone Number:
530-447-0253

Provider Taxonomy Codes

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

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





Copyright © 2007-2026 www.npivalidator.com