1073396594 NPI number — THE HOLISTIC MENTAL HEALTH CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073396594 NPI number — THE HOLISTIC MENTAL HEALTH CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE HOLISTIC MENTAL HEALTH CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073396594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6161 DR MLK JR ST N
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
SAINT PETERSBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-520-9447
Provider Business Mailing Address Fax Number:
727-520-9444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6161 DR MLK JR ST N
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
SAINT PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-520-9447
Provider Business Practice Location Address Fax Number:
727-520-9444
Provider Enumeration Date:
08/17/2023

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
727-599-1292

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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