Healthcare Provider Details

I. General information

NPI: 1568851459
Provider Name (Legal Business Name): INNER WELLNESS THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 39TH ST STE 203
ASTORIA OR
97103-2455
US

IV. Provider business mailing address

100 39TH ST STE 203
ASTORIA OR
97103-2455
US

V. Phone/Fax

Practice location:
  • Phone: 503-468-8646
  • Fax: 503-325-2813
Mailing address:
  • Phone: 503-468-8646
  • Fax: 503-325-2813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL6223
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name: LAUREN ELIZABETH MENGEDOHT
Title or Position: CLINICAL SOCIAL WORKER
Credential: MSW LCSW
Phone: 503-468-8646