Provider Demographics
NPI:1568851459
Name:INNER WELLNESS THERAPY LLC
Entity Type:Organization
Organization Name:INNER WELLNESS THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MENGEDOHT
Authorized Official - Suffix:
Authorized Official - Credentials:MSW LCSW
Authorized Official - Phone:503-468-8646
Mailing Address - Street 1:100 39TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-2455
Mailing Address - Country:US
Mailing Address - Phone:503-468-8646
Mailing Address - Fax:503-325-2813
Practice Address - Street 1:100 39TH ST STE 203
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-2455
Practice Address - Country:US
Practice Address - Phone:503-468-8646
Practice Address - Fax:503-325-2813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL62231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty