MEDICARE: INNER TRAIL THERAPY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1669304838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER TRAIL THERAPY PLLC

Provider Business Mailing Address
First Line	:	1429 DAUNER RD
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-1561
Country	:	US
Telephone Number	:	734-757-3148
Fax Number	:

Provider Business Practice Location Address
First Line	:	1429 DAUNER RD
Second Line	:
City	:	FENTON
State	:	MI
Zip	:	48430-1561
Country	:	US
Telephone Number	:	734-757-3148
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LISA RAE
Credential	:	LCSW
Telephone Number	:	734-757-3148

Provider Enumeration Date	:	06/02/2026
Last Update Date	:	06/02/2026

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