Provider Demographics
NPI:1699507210
Name:ROOT TO VINE PSYCHOTHERAPY
Entity type:Organization
Organization Name:ROOT TO VINE PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:215-391-6325
Mailing Address - Street 1:644 MANOR RD
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08010-1057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:644 MANOR RD
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:NJ
Practice Address - Zip Code:08010-1057
Practice Address - Country:US
Practice Address - Phone:215-391-6325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty