Provider Demographics
NPI:1982105995
Name:INNER DAWN LLC
Entity Type:Organization
Organization Name:INNER DAWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLFY
Authorized Official - Suffix:
Authorized Official - Credentials:CSW
Authorized Official - Phone:517-292-3305
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:MI
Mailing Address - Zip Code:48854-0010
Mailing Address - Country:US
Mailing Address - Phone:517-676-9788
Mailing Address - Fax:
Practice Address - Street 1:257 S MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:ONSTED
Practice Address - State:MI
Practice Address - Zip Code:49265-9682
Practice Address - Country:US
Practice Address - Phone:517-292-3305
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-25
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MI68010946661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty