Healthcare Provider Details

I. General information

NPI: 1164213070
Provider Name (Legal Business Name): WOVEN ROOTS THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2025
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 N 4TH ST
MARQUETTE MI
49855-3401
US

IV. Provider business mailing address

1024 N 4TH ST
MARQUETTE MI
49855-3401
US

V. Phone/Fax

Practice location:
  • Phone: 231-590-0070
  • Fax:
Mailing address:
  • Phone: 231-590-0070
  • 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: COURTNEY LOUISE KING
Title or Position: THERAPIST/ SOCIAL WORKER
Credential: LMSW
Phone: 231-590-0070