Provider Demographics
NPI:1669703070
Name:ROOT, MARIAH ELIZABETH ANN (LMSW, LCSW)
Entity type:Individual
Prefix:MS
First Name:MARIAH
Middle Name:ELIZABETH ANN
Last Name:ROOT
Suffix:
Gender:F
Credentials:LMSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2563 RAYMOND AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-3928
Mailing Address - Country:US
Mailing Address - Phone:517-862-3456
Mailing Address - Fax:847-492-0320
Practice Address - Street 1:2563 RAYMOND AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-3928
Practice Address - Country:US
Practice Address - Phone:517-862-3456
Practice Address - Fax:847-492-0320
Is Sole Proprietor?:No
Enumeration Date:2010-01-25
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011066041041C0700X
IL149.0133391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical