Provider Demographics
NPI:1174242846
Name:INNER WOLF WELLNESS, LLC
Entity type:Organization
Organization Name:INNER WOLF WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:LADC LCMHC
Authorized Official - Phone:802-793-2853
Mailing Address - Street 1:141 MOUNT PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-1139
Mailing Address - Country:US
Mailing Address - Phone:802-793-2137
Mailing Address - Fax:
Practice Address - Street 1:141 MOUNT PLEASANT ST
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-1139
Practice Address - Country:US
Practice Address - Phone:802-793-2137
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health