Provider Demographics
NPI:1437925427
Name:WISDOM WITHIN WELLNESS LLC
Entity Type:Organization
Organization Name:WISDOM WITHIN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER MANAGER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLYJOY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANALEY
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:503-473-2910
Mailing Address - Street 1:3925 SE 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3605
Mailing Address - Country:US
Mailing Address - Phone:503-473-2910
Mailing Address - Fax:844-440-2129
Practice Address - Street 1:1235 SE DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1000
Practice Address - Country:US
Practice Address - Phone:503-473-2910
Practice Address - Fax:844-440-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-30
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health