| Southern Roots Therapeutic Services Llc | |
|
74 Falin Ln Williamsburg KY 40769-1791 | |
| (606) 304-7994 | |
| Not Available |
| Full Name | Southern Roots Therapeutic Services Llc |
|---|---|
| Speciality | Counselor |
| Location | 74 Falin Ln, Williamsburg, Kentucky |
| Authorized Official Name and Position | Melissa Hansford (OWNER) |
| Authorized Official Contact | 6063047994 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Southern Roots Therapeutic Services Llc 74 Falin Ln Williamsburg KY 40769-1791 Ph: (606) 304-7994 | Southern Roots Therapeutic Services Llc 74 Falin Ln Williamsburg KY 40769-1791 Ph: (606) 304-7994 |
| NPI Number | 1851155014 |
|---|---|
| Provider Enumeration Date | 02/08/2024 |
| Last Update Date | 02/08/2024 |
| Certification Date | 02/08/2024 |
| Medicare PECOS PAC ID | 5395184717 |
|---|---|
| Medicare Enrollment ID | O20240418001943 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851155014 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YP2500X | Counselor - Professional | (* (Not Available)) | Primary |
| Provider Name | Melissa Jane Hansford |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1356700710 PECOS PAC ID: 1658710074 Enrollment ID: I20240418002066 |
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