Provider Demographics
NPI:1437931532
Name:HEALING ROOTS THERAPY GROUP
Entity Type:Organization
Organization Name:HEALING ROOTS THERAPY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DIELEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-485-5920
Mailing Address - Street 1:327 BRISTOL AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4927
Mailing Address - Country:US
Mailing Address - Phone:616-485-5920
Mailing Address - Fax:
Practice Address - Street 1:327 BRISTOL AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4927
Practice Address - Country:US
Practice Address - Phone:616-485-5920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty