Provider Demographics
NPI:1528644713
Name:INSPIRED WELLNESS, LLC
Entity type:Organization
Organization Name:INSPIRED WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-CP
Authorized Official - Phone:803-542-4152
Mailing Address - Street 1:501 EVERTON DR
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-7124
Mailing Address - Country:US
Mailing Address - Phone:803-542-4152
Mailing Address - Fax:
Practice Address - Street 1:7511 SAINT ANDREWS RD STE 4
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2894
Practice Address - Country:US
Practice Address - Phone:803-575-0579
Practice Address - Fax:803-830-3873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-19
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSW1739Medicaid