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General NPI Number Information
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NPI Number | 1932834926
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Entity Type | Organization
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Legal Business Name | HOLISTIC ATHLETE LLC
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Dates
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Enumeration Date | 07/22/2022
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Last Update Date | 07/22/2022
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Provider Practice Location Address
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Address Line | 24B ROSEMARY LN
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City | MIDDLEFIELD
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State | CT
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Zip | 06455-1041
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Country | US
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Telephone | 860-877-6093
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Fax |
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Provider Business Mailing Address
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Address Line | 24B ROSEMARY LN
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City | MIDDLEFIELD
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State | CT
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Zip | 06455-1041
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Country | US
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Telephone | 860-877-6093
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ZACHARY ETTER
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Credential | LPC CMPC
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Telephone | 860-877-6093
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC1900X
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Taxonomy Name | Counseling Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TE1100X
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Taxonomy Name | Exercise & Sports Psychologist
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License Number |
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License Number State |
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