Healthcare Provider Details

I. General information

NPI: 1457221004
Provider Name (Legal Business Name): INNER REVOLUTION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2025
Last Update Date: 11/10/2025
Certification Date: 11/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1878 FOURMILE CANYON DR APT 3
BOULDER CO
80302-8772
US

IV. Provider business mailing address

800 N SMITH RD APT 1A
BLOOMINGTON IN
47408-2933
US

V. Phone/Fax

Practice location:
  • Phone: 930-207-9805
  • Fax:
Mailing address:
  • Phone: 930-207-9805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: CHRISTINA L BAME
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 930-207-9805