Healthcare Provider Details

I. General information

NPI: 1477385508
Provider Name (Legal Business Name): WOVEN ROOTS BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 W HAMPTON AVE STE 112
MILWAUKEE WI
53225-4960
US

IV. Provider business mailing address

9120 W HAMPTON AVE STE 112
MILWAUKEE WI
53225-4960
US

V. Phone/Fax

Practice location:
  • Phone: 301-922-3930
  • Fax:
Mailing address:
  • Phone: 301-922-3930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMAL RASHAD CUNNINGHAM
Title or Position: OWNER/LICENSED PSYCHOLOGIST
Credential: PSY.D., M.ED.
Phone: 301-922-3930