| Full Name | Roots 45 |
|---|---|
| Speciality | Clinic/center - Mental Health (including Community Mental Health Center) |
| Location | 100 W 1st St, Gaylord, Michigan |
| Authorized Official Name and Position | Jennifer Ellen Wummel (BH THERAPIST) |
| Authorized Official Contact | 9893503053 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Roots 45 2704 Hickorywood Dr Gaylord MI 49735-6403 Ph: (989) 350-3053 | Roots 45 100 W 1st St Gaylord MI 49735-1355 Ph: (989) 350-3053 |
| NPI Number | 1235725516 |
|---|---|
| Provider Enumeration Date | 12/21/2020 |
| Last Update Date | 12/21/2020 |
| Certification Date | 12/21/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1235725516 | NPI | - | NPPES |
| 6801097139 | Other | MI | MASTER'S SOCIAL WORKER LICENSE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
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› Verified 4 days ago
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