Healthcare Provider Details

I. General information

NPI: 1487596185
Provider Name (Legal Business Name): MADE WHOLE THERAPEUTIC SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 THIMBLE SHOALS BLVD STE 304
NEWPORT NEWS VA
23606-4258
US

IV. Provider business mailing address

311 LIGHTHOUSE WAY
CARROLLTON VA
23314-3364
US

V. Phone/Fax

Practice location:
  • Phone: 804-490-3365
  • Fax:
Mailing address:
  • Phone: 804-490-3365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MATAYA TAYLOR-MAKELL
Title or Position: OWNER
Credential:
Phone: 804-490-3365