Healthcare Provider Details

I. General information

NPI: 1104626944
Provider Name (Legal Business Name): IRON ROOTS RECOVERY & MENTAL WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 W PARK PL STE 105
COEUR D ALENE ID
83814-2787
US

IV. Provider business mailing address

2025 W PARK PL STE 105
COEUR D ALENE ID
83814-2787
US

V. Phone/Fax

Practice location:
  • Phone: 208-659-2049
  • Fax: 208-719-7952
Mailing address:
  • Phone: 208-771-7013
  • Fax: 208-719-7952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER MARIE MAYBERRY
Title or Position: OWNER
Credential: LMSW
Phone: 208-771-7013