=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992226708
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOLISTIC LAKEWOOD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15217 MADISON AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-904-2524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15217 MADISON AVE
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44107-4018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-904-2524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. PAULETTE SIMONETTA
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 216-904-2524
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 33020185
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------