MEDICARE: DEEP ROOTS FAMILY THERAPY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1528865417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEEP ROOTS FAMILY THERAPY

Provider Business Mailing Address
First Line	:	2600 N REYNOLDS RD STE 101A
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-2067
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 N REYNOLDS RD STE 101A
Second Line	:
City	:	TOLEDO
State	:	OH
Zip	:	43615-2067
Country	:	US
Telephone Number	:	419-324-5518
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CYNTHIA CONNOR WAGENHAUSER
Credential	:	LISW
Telephone Number	:	419-324-5518

Provider Enumeration Date	:	02/27/2025
Last Update Date	:	02/27/2025

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Directions to “DEEP ROOTS FAMILY THERAPY ” Practice Location

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