Healthcare Provider Details

I. General information

NPI: 1366379208
Provider Name (Legal Business Name): IRIDESCENCE WELLNESS STUDIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5118 POCONO DR
HUBER HEIGHTS OH
45424-6017
US

IV. Provider business mailing address

5118 POCONO DR
HUBER HEIGHTS OH
45424-6017
US

V. Phone/Fax

Practice location:
  • Phone: 937-626-4807
  • Fax:
Mailing address:
  • Phone: 937-626-4807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: HELENA Q. GRAHAM
Title or Position: OWNER/ SENIOR CLINICIAN
Credential: LPCC, LICDC
Phone: 937-626-4807