Provider Demographics
NPI:1053151902
Name:MY ROOTS OF LIFE
Entity type:Organization
Organization Name:MY ROOTS OF LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSE MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VILMA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRIDO RIQUENES
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:786-234-1609
Mailing Address - Street 1:17025 NW 52ND PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33055-4018
Mailing Address - Country:US
Mailing Address - Phone:786-234-1609
Mailing Address - Fax:
Practice Address - Street 1:12863 SW 42ND ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-3434
Practice Address - Country:US
Practice Address - Phone:786-234-1609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-29
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health