=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760910269
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRAVERSE HOLISTIC SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/26/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3025 NW 26TH ST
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-366-4847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3025 NW 26TH ST
-----------------------------------------------------
City | OAKLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311-2015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-366-4847
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JAMIE O. JOSEPH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 754-366-4847
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------