=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497435580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHOLEHEARTED COUNSELING SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2023
-----------------------------------------------------
Last Update Date | 07/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 ELMIRA TRL
-----------------------------------------------------
City | HOPATCONG
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07843-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-503-7770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 STATE ROUTE 10 # 1013
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07869-1542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. PHADADRIA MICHELE RANDALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-503-7770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------