Provider Demographics
NPI:1063118776
Name:FORTITUDE WELLNESS COLLECTIVE, LLC
Entity type:Organization
Organization Name:FORTITUDE WELLNESS COLLECTIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:
Authorized Official - First Name:RASHONDA
Authorized Official - Middle Name:IESHA
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, LICSW
Authorized Official - Phone:228-218-3593
Mailing Address - Street 1:712 H ST NE STE 1851
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20002-3627
Mailing Address - Country:US
Mailing Address - Phone:202-505-1916
Mailing Address - Fax:
Practice Address - Street 1:3922 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-6325
Practice Address - Country:US
Practice Address - Phone:202-505-1916
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty