Healthcare Provider Details

I. General information

NPI: 1841875390
Provider Name (Legal Business Name): WHOLE HUMAN COUNSELING AND PERFORMANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 S BERMONT AVE
LAFAYETTE CO
80026-1519
US

IV. Provider business mailing address

792 S BERMONT AVE
LAFAYETTE CO
80026-1519
US

V. Phone/Fax

Practice location:
  • Phone: 732-567-6544
  • Fax:
Mailing address:
  • Phone: 732-567-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MACKENZIE BROWN
Title or Position: CLINICAL PSYCHOLOGIST, SPORT PSYCH
Credential: PSYD
Phone: 732-567-6544