Provider Demographics
NPI:1104626944
Name:IRON ROOTS RECOVERY & MENTAL WELLNESS, LLC
Entity type:Organization
Organization Name:IRON ROOTS RECOVERY & MENTAL WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MAYBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:208-659-2049
Mailing Address - Street 1:2025 W PARK PL STE 105
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2787
Mailing Address - Country:US
Mailing Address - Phone:208-659-2049
Mailing Address - Fax:208-719-7952
Practice Address - Street 1:2025 W PARK PL STE 105
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2787
Practice Address - Country:US
Practice Address - Phone:208-659-2049
Practice Address - Fax:208-719-7952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-18
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder