MEDICARE: OLISTICA, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1174179998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OLISTICA, INC.

Provider Business Mailing Address
First Line	:	1405 SILVER LAKE RD NW STE 17
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9309
Country	:	US
Telephone Number	:	763-300-9829
Fax Number	:	612-814-0671

Provider Business Practice Location Address
First Line	:	1405 SILVER LAKE RD NW STE 17
Second Line	:
City	:	NEW BRIGHTON
State	:	MN
Zip	:	55112-9309
Country	:	US
Telephone Number	:	763-300-9829
Fax Number	:	612-814-0671

Authorized Official
Title or Position	:	FOUNDER/COUNSELOR
Name	:	KATHY A DIXON
Credential	:	LPC
Telephone Number	:	763-300-9829

Provider Enumeration Date	:	08/16/2019
Last Update Date	:	08/16/2019

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