Healthcare Provider Details

I. General information

NPI: 1013774587
Provider Name (Legal Business Name): ROOT & VINES WELLNESS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2919 N RACINE AVE BSMT
CHICAGO IL
60657-4223
US

IV. Provider business mailing address

2919 N RACINE AVE BSMT
CHICAGO IL
60657-4223
US

V. Phone/Fax

Practice location:
  • Phone: 505-331-3467
  • Fax:
Mailing address:
  • Phone: 505-331-3467
  • 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 State

VIII. Authorized Official

Name: IVY F MALISOW
Title or Position: THERAPIST
Credential: LCPC
Phone: 505-331-3467