Provider Demographics
NPI:1366086779
Name:WHITE OWL WELLNESS LLC
Entity type:Organization
Organization Name:WHITE OWL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:IPPOLITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-214-1160
Mailing Address - Street 1:12 KNOLLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FLANDERS
Mailing Address - State:NJ
Mailing Address - Zip Code:07836-9306
Mailing Address - Country:US
Mailing Address - Phone:973-214-1160
Mailing Address - Fax:
Practice Address - Street 1:151 ROUTE 10 STE 106
Practice Address - Street 2:
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1452
Practice Address - Country:US
Practice Address - Phone:973-214-1160
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty