Provider Demographics
NPI:1619560166
Name:THE ROOT NETWORK, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Entity Type:Organization
Organization Name:THE ROOT NETWORK, A LICENSED CLINICAL SOCIAL WORKER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARSHIQ
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:909-235-9880
Mailing Address - Street 1:2990 INLAND EMPIRE BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4899
Mailing Address - Country:US
Mailing Address - Phone:909-235-9880
Mailing Address - Fax:
Practice Address - Street 1:2990 INLAND EMPIRE BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4899
Practice Address - Country:US
Practice Address - Phone:909-235-9880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-16
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty