Basic Information
| Provider Information | |||||||||
| NPI: | 1174192751 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MENDING ROOTS HEALING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 87 BOTANY DR | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288051631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276435594 | ||||||||
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| Practice Location | |||||||||
| Address1: | 577 HAYWOOD RD | ||||||||
| Address2: | |||||||||
| City: | ASHEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 288063559 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276435594 | ||||||||
| FaxNumber: | 7276435594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2021 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| AuthorizedOfficialLastName: | KICKLITER | ||||||||
| AuthorizedOfficialFirstName: | LYDIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7276435594 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCMHC | ||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.