Healthcare Provider Details

I. General information

NPI: 1396676367
Provider Name (Legal Business Name): INTERWOVEN ROOTS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N RANDOLPH ST STE 432
CHAMPAIGN IL
61820-3978
US

IV. Provider business mailing address

1008 S WABASH AVE
URBANA IL
61801-5216
US

V. Phone/Fax

Practice location:
  • Phone: 217-621-5609
  • Fax:
Mailing address:
  • Phone: 217-621-5609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: SANDRA JOY SHANNON
Title or Position: SOCIAL WORKER
Credential: LCSW
Phone: 217-621-5609