=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043835895
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC VIDA THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2020
-----------------------------------------------------
Last Update Date | 11/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3610 LAUREATE DR
-----------------------------------------------------
City | HOLT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48842-9422
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-455-7555
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 119 PERE MARQUETTE DR STE 2D
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48912-1270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ILLAMI ROMERO MARTINEZ
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 517-944-1262
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------