NPIMap

Organization Active NPI

Deep Roots Wellness, LLC

  • Mental Health Counselor
  • Defiance, OH
National Provider Identifier
1942799515
Registry record updated Oct 12, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mental Health CounselorTaxonomy code 101YM0800X
License
E0600346 Issued in OH
Legal business name
DEEP ROOTS WELLNESS, LLC
Practice address
8081 Adams Ridge Rd
Defiance, OH 43512-9173
Phone
(419) 239-2113
Fax
(419) 239-2113
NPI assigned
May 8, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 12, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Matthew Hollo, LPCC-SNPI 1629305586
Title
Owner
Phone
(419) 239-2113

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mental Health CounselorGroup: 193400000X SINGLE SPECIALTY GROUP 101YM0800X E0600346 OH Primary

Addresses

Primary practice location

8081 Adams Ridge Rd
Defiance, OH 43512-9173

Mailing address

105 Westfield Ave
Defiance, OH 43512-1433
Phone (419) 239-2113

Other identifiers 2

IdentifierTypeStateIssuer
0157085MedicaidOH
0282598MedicaidOH

National Provider Directory

National Provider Directory

Locations

950 Webster St
Defiance, OH 43512

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1525737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1602460800000",
    "number": "1942799515",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "105 WESTFIELD AVE",
            "city": "DEFIANCE",
            "state": "OH",
            "postal_code": "435121433",
            "telephone_number": "419-239-2113"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8081 ADAMS RIDGE RD",
            "city": "DEFIANCE",
            "state": "OH",
            "postal_code": "435129173",
            "telephone_number": "419-239-2113",
            "fax_number": "419-239-2113"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DEEP ROOTS WELLNESS, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-05-08",
        "last_updated": "2020-10-12",
        "certification_date": "2020-10-12",
        "status": "A",
        "authorized_official_last_name": "HOLLO",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "419-239-2113",
        "authorized_official_credential": "LPCC-S"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Mental Health",
            "state": "OH",
            "license": "E0600346",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0157085",
            "state": "OH"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "0282598",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Defiance, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 12, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.