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General NPI Number Information
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NPI Number | 1598308322
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Entity Type | Organization
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Legal Business Name | DEEP ROOTS WELLNESS
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Dates
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Enumeration Date | 10/24/2019
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Last Update Date | 08/06/2020
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Provider Practice Location Address
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Address Line | 733 W. 40TH STREET PRINT SHOP BUILDING SUITE 20
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City | BALTIMORE
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State | MD
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Zip | 21211
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Country | US
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Telephone | 443-297-9693
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Fax |
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Provider Business Mailing Address
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Address Line | 3721 REXMERE RD
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City | BALTIMORE
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State | MD
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Zip | 21218-2011
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JEREMY BRAVERMAN
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Credential | LAC MAC
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Telephone | 443-297-9693
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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