Provider Demographics
NPI:1548906803
Name:INTENTIONAL SUSTAINABLE WELLNESS
Entity type:Organization
Organization Name:INTENTIONAL SUSTAINABLE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER, PSYCHIATRY DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARIVIERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:612-723-6417
Mailing Address - Street 1:4127 NORD HWY
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-9631
Mailing Address - Country:US
Mailing Address - Phone:612-723-6417
Mailing Address - Fax:
Practice Address - Street 1:4127 NORD HWY
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-9631
Practice Address - Country:US
Practice Address - Phone:612-723-6417
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-10
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA553997OtherCALIFORNIA MEDICAL BOARD FICTITIOUS NAME PERMIT (FNP)
CA4571750OtherENTITY (FILE) NUMBER