Provider Demographics
NPI:1942799515
Name:DEEP ROOTS WELLNESS, LLC
Entity Type:Organization
Organization Name:DEEP ROOTS WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLO
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC-S
Authorized Official - Phone:419-239-2113
Mailing Address - Street 1:105 WESTFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-1433
Mailing Address - Country:US
Mailing Address - Phone:419-239-2113
Mailing Address - Fax:
Practice Address - Street 1:8081 ADAMS RIDGE RD
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-9173
Practice Address - Country:US
Practice Address - Phone:419-239-2113
Practice Address - Fax:419-239-2113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0600346101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0157085Medicaid
OH0282598Medicaid