Provider Demographics
NPI:1023739067
Name:ROUNDTABLE WELLNESS
Entity type:Organization
Organization Name:ROUNDTABLE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, CEO, CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:TILT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-630-7222
Mailing Address - Street 1:904 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47901-1416
Mailing Address - Country:US
Mailing Address - Phone:765-630-7222
Mailing Address - Fax:765-630-7905
Practice Address - Street 1:90 EXECUTIVE DR STE C
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-2612
Practice Address - Country:US
Practice Address - Phone:765-630-7222
Practice Address - Fax:765-630-7905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty