Provider Demographics
NPI:1598387128
Name:DEEPER ROOTS WELLNESS LLC
Entity Type:Organization
Organization Name:DEEPER ROOTS WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DELIRA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, IECMH-E
Authorized Official - Phone:313-720-4522
Mailing Address - Street 1:33550 STOCKER ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-5361
Mailing Address - Country:US
Mailing Address - Phone:313-720-4522
Mailing Address - Fax:
Practice Address - Street 1:34024 W 8 MILE RD STE 104
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-5209
Practice Address - Country:US
Practice Address - Phone:313-437-1869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)