Organization
ROOT & VINES WELLNESS, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
IVY F MALISOW LCPC (THERAPIST)
(505) 331-3467
Entity
Organization
Contact information
Practice address
2919 N RACINE AVE BSMT, CHICAGO, IL 60657-4223
(505) 331-3467
Mailing address
2919 N RACINE AVE BSMT, CHICAGO, IL 60657-4223
(505) 331-3467
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Enumeration date
03/01/2024
Last updated
03/01/2024
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