1902308604 NPI number — HOLISTIC BEHAVIORAL HEALTH, LLC

Table of content: (NPI 1902308604)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902308604 NPI number — HOLISTIC BEHAVIORAL HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLISTIC BEHAVIORAL HEALTH, LLC
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:
HOLISTIC BEHAVIORAL HEALTH, LLC
Provider Other Organization Name Type Code:
4
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:
1902308604
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
81 GILBERT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMDEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06514-3352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-243-0060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 DIXWELL AVE UNIT D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAMDEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06514-3147
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-604-9009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
DA CRUZ
Authorized Official First Name:
LA'SHONDRA
Authorized Official Middle Name:
MONIQUE
Authorized Official Title or Position:
OWNER/CLINICIAN
Authorized Official Telephone Number:
203-243-0060

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  003264 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1124445663 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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