Provider Demographics
NPI:1598308322
Name:DEEP ROOTS WELLNESS
Entity Type:Organization
Organization Name:DEEP ROOTS WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAVERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LAC MAC
Authorized Official - Phone:443-297-9693
Mailing Address - Street 1:3721 REXMERE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-2011
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:733 W. 40TH STREET
Practice Address - Street 2:PRINT SHOP BUILDING SUITE 20
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21211
Practice Address - Country:US
Practice Address - Phone:443-297-9693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-24
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty