Provider Demographics
NPI:1679334080
Name:ROOT AND REVIVE WELLNESS LLC
Entity type:Organization
Organization Name:ROOT AND REVIVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRITNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-525-3703
Mailing Address - Street 1:5335 W 48TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80212-2700
Mailing Address - Country:US
Mailing Address - Phone:303-525-3703
Mailing Address - Fax:
Practice Address - Street 1:5335 W 48TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80212-2700
Practice Address - Country:US
Practice Address - Phone:303-525-3703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-22
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty