Provider Demographics
NPI:1861023756
Name:ROOTS THERAPEUTIC SPECIALTY SERVICES
Entity Type:Organization
Organization Name:ROOTS THERAPEUTIC SPECIALTY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:OSIPSOV
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-481-8919
Mailing Address - Street 1:10263 CHICAGO DR
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-1416
Mailing Address - Country:US
Mailing Address - Phone:616-377-2283
Mailing Address - Fax:
Practice Address - Street 1:10263 CHICAGO DR
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-1416
Practice Address - Country:US
Practice Address - Phone:616-377-2283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
13582106OtherCAQH