Healthcare Provider Details

I. General information

NPI: 1760355929
Provider Name (Legal Business Name): MARIAH ROOT, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 WEALTHY ST SE
GRAND RAPIDS MI
49506-2717
US

IV. Provider business mailing address

2563 RAYMOND AVE SE
GRAND RAPIDS MI
49507-3928
US

V. Phone/Fax

Practice location:
  • Phone: 517-862-3456
  • Fax:
Mailing address:
  • Phone: 517-862-3456
  • 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: MARIAH ROOT
Title or Position: PSYCHOTHERAPIST
Credential: LMSW
Phone: 518-862-3456