Healthcare Provider Details

I. General information

NPI: 1467271304
Provider Name (Legal Business Name): WHOLESOME BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8517 AIRLINE AVE
URBANDALE IA
50322-2317
US

IV. Provider business mailing address

115 GOLDEN GATE PKWY
WENTZVILLE MO
63385-7288
US

V. Phone/Fax

Practice location:
  • Phone: 636-634-5668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EBITARI FREGENE
Title or Position: CEO
Credential: DNP
Phone: 314-397-7219