Healthcare Provider Details

I. General information

NPI: 1609587120
Provider Name (Legal Business Name): HOLISTIC WELLNESS SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3806 RAVENWOOD AVE
BALTIMORE MD
21213-2022
US

IV. Provider business mailing address

PO BOX 3394
BALTIMORE MD
21213-0394
US

V. Phone/Fax

Practice location:
  • Phone: 443-629-0646
  • Fax:
Mailing address:
  • Phone: 443-629-0646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: VICKIE COOKE
Title or Position: CEO / FOUNDER
Credential: LCADC
Phone: 443-629-0646