Healthcare Provider Details

I. General information

NPI: 1902766520
Provider Name (Legal Business Name): HAVENROOT THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 BELLEVILLE AVE
BALTIMORE MD
21207-6945
US

IV. Provider business mailing address

5535 BELLEVILLE AVE
BALTIMORE MD
21207-6945
US

V. Phone/Fax

Practice location:
  • Phone: 443-502-0825
  • Fax:
Mailing address:
  • Phone:
  • 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: IKECHUKWU NWAKANMA
Title or Position: MANAGING PARTNER
Credential:
Phone: 443-502-0825