=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841900115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE HOLISTIC WELLNESS LOUNGE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2022
-----------------------------------------------------
Last Update Date | 11/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12530 FAIRWOOD PKWY STE 102
-----------------------------------------------------
City | BOWIE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20720-6357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-531-1114
-----------------------------------------------------
Fax | 855-512-3111
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84 SOUTHGATE SQ # 1177
-----------------------------------------------------
City | COLONIAL HEIGHTS
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23834-3611
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-531-1114
-----------------------------------------------------
Fax | 855-512-3111
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | CARLA HALL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 855-531-1114
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------