Provider Demographics
NPI:1093377418
Name:DEEP ROOTS COUNSELING GROUP LLC
Entity Type:Organization
Organization Name:DEEP ROOTS COUNSELING GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:KERRIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CUSACK
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:774-571-9069
Mailing Address - Street 1:21 BLACKSTONE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02019-1601
Mailing Address - Country:US
Mailing Address - Phone:774-571-9069
Mailing Address - Fax:
Practice Address - Street 1:21 BLACKSTONE ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:MA
Practice Address - Zip Code:02019-1601
Practice Address - Country:US
Practice Address - Phone:774-571-9069
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-05
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty