Healthcare Provider Details

I. General information

NPI: 1013608264
Provider Name (Legal Business Name): DEEPLY ROOTED THERAPEUTIC SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E 87TH ST STE 104A
CHICAGO IL
60617-2706
US

IV. Provider business mailing address

1750 E 87TH ST STE 104A
CHICAGO IL
60617-2706
US

V. Phone/Fax

Practice location:
  • Phone: 872-395-1345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. LATESHA JAMARI HARRIS-BOYD
Title or Position: OWNER AND CEO
Credential: LCSW
Phone: 872-935-1345