Provider Demographics
NPI:1639971203
Name:DEEP ROOTS HEALING, PLLC
Entity type:Organization
Organization Name:DEEP ROOTS HEALING, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:GAUDENCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PALOMO-BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:701-787-1332
Mailing Address - Street 1:311 S 4TH ST STE 116
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4792
Mailing Address - Country:US
Mailing Address - Phone:701-620-9876
Mailing Address - Fax:
Practice Address - Street 1:311 S 4TH ST STE 116
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4792
Practice Address - Country:US
Practice Address - Phone:701-620-9876
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-25
Last Update Date:2025-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty