Basic Information
| Provider Information | |||||||||
| NPI: | 1376121772 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TAPROOT THERAPY COLLECTIVE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3204 ALTALOMA DR | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA HILLS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352164265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059999240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2025 SHADY CREST DR | ||||||||
| Address2: | |||||||||
| City: | HOOVER | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352165417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059999240 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2021 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLACKSTOCK | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2059999240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | LICSW MSW PIP | ||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 1041C0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 4135C | 01 | AL | LICSW | OTHER |