Healthcare Provider Details

I. General information

NPI: 1831617448
Provider Name (Legal Business Name): INNER PATH WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2017
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ROSEMONT AVE NE APT C
ALBUQUERQUE NM
87102-1599
US

IV. Provider business mailing address

300 MENAUL BLVD NW STE A PMB 468
ALBUQUERQUE NM
87107-9951
US

V. Phone/Fax

Practice location:
  • Phone: 505-750-3605
  • Fax: 505-340-3941
Mailing address:
  • Phone: 505-750-3605
  • Fax: 505-340-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-09020
License Number StateNM

VIII. Authorized Official

Name: MS. JESSICA AYESHA RODRIGUES SUNDRAM
Title or Position: OWNER
Credential: LCSW
Phone: 505-750-3605