Provider Demographics
NPI:1043880149
Name:ROOTED THERAPEUTIC SERVICES, PLLC
Entity type:Organization
Organization Name:ROOTED THERAPEUTIC SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VONETTA
Authorized Official - Middle Name:BUTLER
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LISW-CP
Authorized Official - Phone:704-989-3459
Mailing Address - Street 1:10337 ELVEN LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-6964
Mailing Address - Country:US
Mailing Address - Phone:704-989-3459
Mailing Address - Fax:
Practice Address - Street 1:10337 ELVEN LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-6964
Practice Address - Country:US
Practice Address - Phone:704-989-3459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-30
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1083219588Medicaid