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General NPI Number Information
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NPI Number | 1912365255
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Entity Type | Organization
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Legal Business Name | DEEP ROOTS THERAPY, PLLC
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Dates
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Enumeration Date | 02/01/2016
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Last Update Date | 02/01/2016
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Provider Practice Location Address
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Address Line | 2319 N 45TH ST #110
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City | SEATTLE
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State | WA
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Zip | 98103-6982
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Country | US
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Telephone | 951-295-4911
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Fax |
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Provider Business Mailing Address
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Address Line | 6322 5TH AVE NE
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City | SEATTLE
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State | WA
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Zip | 98115-6518
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Country | US
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Telephone | 951-295-4911
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Fax |
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Authorized Official
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Title or Position | OWER; MARRIAGE AND FAMILY THERAPIST
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Name | KELLEY CRANE
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Credential | MA, LMFT
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Telephone | 951-295-4911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | LF60445167
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License Number State | WA
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