RESTORED ROOTS COUNSELING & WELLNESS — NPI 1922695758 (Licensed & Credentialed Behavioral Health & Social Service Providers

CMS-1500 Box 24J / 33a • NPI

1922695758

Type 2 Organization (Box 32a/33a)

HIPAA NUCC Taxonomy • CMS Code

1041C0700X (CMS 80)

Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical

Box 32 Service Location & ZIP+4

4938 STATE ROUTE 111, ANTWERP, OH, 45813-9724

✓ 9-Digit EDI 837 ZIP+4 (45813-9724)

Practice Phone & Referral Fax

(419) 605-8722

Direct NPPES Verification Line

✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR: NPI 1922695758 (RESTORED ROOTS COUNSELING & WELLNESS) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).

CMS Medicare Order & Referring PECOS Eligibility

Institutional Type-2 NPI facilities enroll via CMS-855A institutional provider agreements rather than individual Order & Referring PECOS.

Official CMS NPPES Credential & Practice Profile

10-Digit NPI Number	`1922695758` (NPI-2 Organization / Facility)
Provider / Legal Name	RESTORED ROOTS COUNSELING & WELLNESS
Plain-English Specialty	Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical NUCC Code: `1041C0700X` (Social Worker, Clinical)
Certifying / Licensing Body	State Medical / Healthcare Licensing Board & National Specialty Board
Practice Location Address	4938 STATE ROUTE 111, ANTWERP, OH, 45813-9724
Practice Telephone / Fax	Tel: (419) 605-8722
Administrative Mailing Address	4938 STATE ROUTE 111, ANTWERP, OH, 45813-9724
Enumeration & Last Sync	Enumerated: 2020-12-28 \| CMS Record Updated: 2020-12-28
Authorized Official	KAYLA GLADIEUX (Owner/Clinician)

Clinic Location, Accessibility & Directions

📍 Practice Location & Patient Access

4938 STATE ROUTE 111, ANTWERP, OH, 45813-9724

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Plain-English Taxonomy & CMS Crosswalk (1041C0700X)

What Does Taxonomy Code 1041C0700X Mean?

In the HIPAA National Uniform Claim Committee (NUCC) classification, code 1041C0700X translates to:
"Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical"

CMS-1500 Medicare Specialty Crosswalk: CMS Code 80 (Licensed Clinical Social Worker)
Certifying / Accrediting Authority: State Medical / Healthcare Licensing Board & National Specialty Board
Clinical Scope: Consult a verified Social Worker, Clinical for specialized diagnostic evaluation, treatment planning, and continuity of care.

Specialty Clinical Procedures & Therapeutic Classes

Standard Scope of Care (RESTORED ROOTS COUNSELING & WELLNESS)

Typical CPT / Diagnostic Procedures:

Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
Preventive Screening, Patient Counseling & Multidisciplinary Referral

Common Therapeutic Classes:

Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)

All Registered NUCC Taxonomies & State Licenses

Taxonomy Code & Plain-English Description	State License & Primary Status
`106H00000X` — Marriage & Family Therapist Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Marriage and Family Therapist	State: N/A \| License: `Verified` \| Primary: Secondary
`1041C0700X` — Social Worker, Clinical Plain English: Licensed & Credentialed Behavioral Health & Social Service Providers — Social Worker, Clinical	State: N/A \| License: `Verified` \| Primary: Yes (Primary)

Medical Billing, RCM & Hospital Credentialing Teams:

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RESTORED ROOTS COUNSELING & WELLNESS (NPI #1922695758)