Provider Demographics
NPI:1679398333
Name:RECOVERED ROOTS COUNSELING LLC
Entity type:Organization
Organization Name:RECOVERED ROOTS COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-451-5148
Mailing Address - Street 1:2850 SW CEDAR HILLS BLVD # 2064
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1354
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2291 NW OAK KNOLL PL
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-8075
Practice Address - Country:US
Practice Address - Phone:503-451-5148
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty