Healthcare Provider Details

I. General information

NPI: 1730043696
Provider Name (Legal Business Name): HOLISTIC HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

397 BRIDGE ST FL 7
BROOKLYN NY
11201-5247
US

IV. Provider business mailing address

PO BOX 232
PETERSBURG NY
12138-0232
US

V. Phone/Fax

Practice location:
  • Phone: 518-321-6888
  • Fax:
Mailing address:
  • Phone: 518-321-6888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. EDWARD PERROTTI-SOUSIS
Title or Position: OWNER
Credential: DSW, LCSW
Phone: 518-321-6888