Provider Demographics
NPI:1982454377
Name:INNERCORE TRANSFORMATION
Entity Type:Organization
Organization Name:INNERCORE TRANSFORMATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:907-775-8742
Mailing Address - Street 1:1403 LOBO TRL
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-5465
Mailing Address - Country:US
Mailing Address - Phone:190-777-5874
Mailing Address - Fax:888-265-5270
Practice Address - Street 1:1403 LOBO TRL
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-5465
Practice Address - Country:US
Practice Address - Phone:190-777-5874
Practice Address - Fax:888-265-5270
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health