Provider Demographics
NPI:1205300837
Name:TABULA RASA WELLNESS LLC
Entity type:Organization
Organization Name:TABULA RASA WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CROWNER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:509-430-7578
Mailing Address - Street 1:3434 LIBERTY RD S APT 65
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-6628
Mailing Address - Country:US
Mailing Address - Phone:509-430-7578
Mailing Address - Fax:503-967-3683
Practice Address - Street 1:2105 LIBERTY ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-8353
Practice Address - Country:US
Practice Address - Phone:503-967-3428
Practice Address - Fax:503-967-3683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-16
Last Update Date:2021-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty