Healthcare Provider Details

I. General information

NPI: 1902308604
Provider Name (Legal Business Name): HOLISTIC BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2018
Last Update Date: 10/29/2022
Certification Date: 10/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 DIXWELL AVE UNIT D
HAMDEN CT
06514-3147
US

IV. Provider business mailing address

81 GILBERT AVE
HAMDEN CT
06514-3352
US

V. Phone/Fax

Practice location:
  • Phone: 203-604-9009
  • Fax:
Mailing address:
  • Phone: 203-243-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number003264
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. LA'SHONDRA MONIQUE DA CRUZ
Title or Position: OWNER/CLINICIAN
Credential: LPC
Phone: 203-243-0060