=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548906803
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTENTIONAL SUSTAINABLE WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2022
-----------------------------------------------------
Last Update Date | 05/10/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4127 NORD HWY
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-9631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-723-6417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4127 NORD HWY
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-9631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-723-6417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER, PSYCHIATRY DIRECTOR
-----------------------------------------------------
Name | LORI L LARIVIERE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 612-723-6417
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------