Provider Demographics
NPI:1528865417
Name:DEEP ROOTS FAMILY THERAPY
Entity type:Organization
Organization Name:DEEP ROOTS FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:CONNOR
Authorized Official - Last Name:WAGENHAUSER
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:419-324-5518
Mailing Address - Street 1:2600 N REYNOLDS RD STE 101A
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-2067
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 N REYNOLDS RD STE 101A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2067
Practice Address - Country:US
Practice Address - Phone:419-324-5518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty