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General NPI Number Information
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NPI Number | 1902603434
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Entity Type | Organization
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Legal Business Name | IVY ROOTS LLC
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 3422 R ST
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City | RICHMOND
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State | VA
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Zip | 23223-6877
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Country | US
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Telephone | 804-896-6607
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Fax | 804-896-6607
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Provider Business Mailing Address
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Address Line | 3422 R ST
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City | RICHMOND
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State | VA
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Zip | 23223-6877
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Country | US
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Telephone | 804-896-6607
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Fax | 804-896-6607
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Authorized Official
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Title or Position | CEO/ OWNER
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Name | SHANELL JANESE WILLIAMS
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Credential | B.S, QMHP-A
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Telephone | 804-896-6607
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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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 | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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