Healthcare Provider Details

I. General information

NPI: 1255760955
Provider Name (Legal Business Name): WHOLEHEARTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2013
Last Update Date: 05/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 W HOLMES RD SUITES 227 A & C
LANSING MI
48910-0426
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-303-4185
  • Fax:
Mailing address:
  • Phone: 517-676-9788
  • Fax: 517-676-3438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801086618
License Number StateMI

VIII. Authorized Official

Name: NEDRA YVONNE CANNON
Title or Position: OWNER
Credential: LMSW
Phone: 517-676-9788