Provider Demographics
NPI: | 1932649662 |
---|---|
Name: | INNER SELF AND WISDOM, LLC |
Entity Type: | Organization |
Organization Name: | INNER SELF AND WISDOM, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO AND FOUNDER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | JASON |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | SHANKLE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MA, LPCC, LACC, CMIT |
Authorized Official - Phone: | 720-975-4368 |
Mailing Address - Street 1: | 15703 E CASPIAN CIR APT 201 |
Mailing Address - Street 2: | |
Mailing Address - City: | AURORA |
Mailing Address - State: | CO |
Mailing Address - Zip Code: | 80013-6314 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 720-975-4368 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 12101 E 2ND AVE |
Practice Address - Street 2: | |
Practice Address - City: | AURORA |
Practice Address - State: | CO |
Practice Address - Zip Code: | 80011-8327 |
Practice Address - Country: | US |
Practice Address - Phone: | 720-975-4368 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-02-28 |
Last Update Date: | 2017-02-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CO | NLC.0107047 | 251S00000X |
CO | LPCC.0013487 | 251S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 251S00000X | Agencies | Community/Behavioral Health |