Provider Demographics
NPI:1720965908
Name:INNER DOMAIN HOLISTIC HEALTH, LLC
Entity type:Organization
Organization Name:INNER DOMAIN HOLISTIC HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, PMHNP
Authorized Official - Phone:503-880-9160
Mailing Address - Street 1:2423 SE 49TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1561
Mailing Address - Country:US
Mailing Address - Phone:503-880-9160
Mailing Address - Fax:
Practice Address - Street 1:6700 SW 105TH AVE STE 211
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-8824
Practice Address - Country:US
Practice Address - Phone:503-974-4624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)