Provider Demographics
NPI:1831617448
Name:INNER PATH WELLNESS, LLC
Entity type:Organization
Organization Name:INNER PATH WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JESSICA AYESHA
Authorized Official - Middle Name:RODRIGUES
Authorized Official - Last Name:SUNDRAM
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:505-750-3605
Mailing Address - Street 1:300 MENAUL BLVD NW STE A PMB 468
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-9951
Mailing Address - Country:US
Mailing Address - Phone:505-750-3605
Mailing Address - Fax:505-340-3941
Practice Address - Street 1:200 ROSEMONT AVE NE APT C
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1599
Practice Address - Country:US
Practice Address - Phone:505-750-3605
Practice Address - Fax:505-340-3941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-03
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-090201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59605251Medicaid