Provider Demographics
NPI:1174351704
Name:ROOTING WILD MOVEMENT LLC
Entity type:Organization
Organization Name:ROOTING WILD MOVEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:985-257-6774
Mailing Address - Street 1:PO BOX 5600
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-0600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4130 RIDGE AVE STE 5600
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19129-1534
Practice Address - Country:US
Practice Address - Phone:985-257-6774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty