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General NPI Number Information
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NPI Number | 1104626944
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Entity Type | Organization
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Legal Business Name | IRON ROOTS RECOVERY & MENTAL WELLNESS, LLC
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Dates
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Enumeration Date | 03/18/2025
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Last Update Date | 05/13/2025
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Provider Practice Location Address
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Address Line | 2025 W PARK PL STE 105
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2787
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Country | US
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Telephone | 208-659-2049
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Fax | 208-719-7952
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Provider Business Mailing Address
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Address Line | 2025 W PARK PL STE 105
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2787
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Country | US
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Telephone | 208-659-2049
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Fax | 208-719-7952
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Authorized Official
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Title or Position | OWNER
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Name | JENNIFER MARIE MAYBERRY
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Credential | LMSW
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Telephone | 208-659-2049
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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