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General NPI Number Information
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NPI Number | 1205300837
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Entity Type | Organization
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Legal Business Name | TABULA RASA WELLNESS LLC
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Dates
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Enumeration Date | 01/16/2019
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Last Update Date | 01/31/2021
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Provider Practice Location Address
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Address Line | 2105 LIBERTY ST NE
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City | SALEM
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State | OR
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Zip | 97301-8353
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Country | US
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Telephone | 503-967-3428
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Fax | 503-967-3683
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Provider Business Mailing Address
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Address Line | 3434 LIBERTY RD S APT 65
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City | SALEM
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State | OR
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Zip | 97302-6628
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Country | US
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Telephone | 509-430-7578
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Fax | 503-967-3683
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Authorized Official
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Title or Position | OWNER/CLINICAL SOCIAL WORKER
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Name | LINDSAY CROWNER
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Credential | LCSW
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Telephone | 509-430-7578
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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