Provider Demographics
NPI:1386417590
Name:ROOT AND BLOOM WELLNESS LLC
Entity type:Organization
Organization Name:ROOT AND BLOOM WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LEAD THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:FAITH
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-340-5617
Mailing Address - Street 1:3090 AMON AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-3059
Mailing Address - Country:US
Mailing Address - Phone:616-340-5617
Mailing Address - Fax:
Practice Address - Street 1:4867 E BELTLINE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9787
Practice Address - Country:US
Practice Address - Phone:616-340-5617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty