Provider Demographics
NPI:1346606456
Name:DEEPLY ROOTED INC
Entity Type:Organization
Organization Name:DEEPLY ROOTED INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-287-8713
Mailing Address - Street 1:124 MAIN ST E
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-3416
Mailing Address - Country:US
Mailing Address - Phone:252-332-2025
Mailing Address - Fax:252-332-5099
Practice Address - Street 1:124 MAIN ST E
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-3416
Practice Address - Country:US
Practice Address - Phone:252-332-2025
Practice Address - Fax:252-332-5099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251B00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management