Provider Demographics
NPI:1225780422
Name:INNER HAVEN WELLNESS, LLC
Entity Type:Organization
Organization Name:INNER HAVEN WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLEMI
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:920-248-0578
Mailing Address - Street 1:818 WEST STREET
Mailing Address - Street 2:SUITE 814
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-3608
Mailing Address - Country:US
Mailing Address - Phone:920-322-5483
Mailing Address - Fax:
Practice Address - Street 1:401 CHARMANY DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1272
Practice Address - Country:US
Practice Address - Phone:608-733-0268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100204138Medicaid