Provider Demographics
NPI:1609331206
Name:INTEGRATIVE THERAPIES WALLA WALLA, LLC
Entity Type:Organization
Organization Name:INTEGRATIVE THERAPIES WALLA WALLA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELISE
Authorized Official - Middle Name:
Authorized Official - Last Name:OCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:773-349-6778
Mailing Address - Street 1:19 E BIRCH ST STE 104
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3205
Mailing Address - Country:US
Mailing Address - Phone:773-349-6778
Mailing Address - Fax:
Practice Address - Street 1:19 E BIRCH ST STE 104
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3205
Practice Address - Country:US
Practice Address - Phone:773-349-6778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-07
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty