Provider Demographics
NPI:1912365255
Name:DEEP ROOTS THERAPY, PLLC
Entity Type:Organization
Organization Name:DEEP ROOTS THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER; MARRIAGE AND FAMILY THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANE
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMFT
Authorized Official - Phone:951-295-4911
Mailing Address - Street 1:6322 5TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6518
Mailing Address - Country:US
Mailing Address - Phone:951-295-4911
Mailing Address - Fax:
Practice Address - Street 1:2319 N 45TH ST
Practice Address - Street 2:#110
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98103-6982
Practice Address - Country:US
Practice Address - Phone:951-295-4911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60445167106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty