Provider Demographics
NPI:1902603434
Name:IVY ROOTS LLC
Entity type:Organization
Organization Name:IVY ROOTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANELL
Authorized Official - Middle Name:JANESE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QMHP-A
Authorized Official - Phone:804-896-6607
Mailing Address - Street 1:3422 R ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23223-6877
Mailing Address - Country:US
Mailing Address - Phone:804-896-6607
Mailing Address - Fax:804-896-6607
Practice Address - Street 1:3422 R ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23223-6877
Practice Address - Country:US
Practice Address - Phone:804-896-6607
Practice Address - Fax:804-896-6607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health