Healthcare Provider Details

I. General information

NPI: 1306676069
Provider Name (Legal Business Name): HOLISTIC PSYCHOLOGY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 W CLARKSTON RD
LAKE ORION MI
48362-2892
US

IV. Provider business mailing address

2450 PERRY LAKE RD
ORTONVILLE MI
48462-9210
US

V. Phone/Fax

Practice location:
  • Phone: 248-989-6128
  • Fax:
Mailing address:
  • Phone: 248-989-6128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: BETHANY ANNE CRISP
Title or Position: MASTER'S LEVEL PSYCHOLOGIST
Credential: LLP
Phone: 248-989-6128