Provider Demographics
NPI:1992077622
Name:INNER WELLTH LLC
Entity type:Organization
Organization Name:INNER WELLTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:SHIPON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:973-321-4380
Mailing Address - Street 1:420 BOULEVARD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1742
Mailing Address - Country:US
Mailing Address - Phone:973-321-4380
Mailing Address - Fax:973-794-5350
Practice Address - Street 1:420 BOULEVARD
Practice Address - Street 2:SUITE 101
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1742
Practice Address - Country:US
Practice Address - Phone:973-321-4380
Practice Address - Fax:973-794-5350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00473800251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health