Healthcare Provider Details

I. General information

NPI: 1902603434
Provider Name (Legal Business Name): IVY ROOTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3422 R ST
RICHMOND VA
23223-6877
US

IV. Provider business mailing address

3422 R ST
RICHMOND VA
23223-6877
US

V. Phone/Fax

Practice location:
  • Phone: 804-896-6607
  • Fax: 804-896-6607
Mailing address:
  • Phone: 804-896-6607
  • Fax: 804-896-6607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SHANELL JANESE WILLIAMS
Title or Position: CEO/ OWNER
Credential: B.S, QMHP-A
Phone: 804-896-6607