MEDICARE: LOOSELEAF HOLISTIC WELLNESS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
3	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295331114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOOSELEAF HOLISTIC WELLNESS

Provider Business Mailing Address
First Line	:	290 NW PEACOCK BLVD UNIT 881444
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34988-5063
Country	:	US
Telephone Number	:	772-208-8773
Fax Number	:

Provider Business Practice Location Address
First Line	:	3603 WILDERNESS DR E
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-6562
Country	:	US
Telephone Number	:	772-208-8773
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	LETITIA LAURIEN
Credential	:	LCSW
Telephone Number	:	772-678-1397

Provider Enumeration Date	:	12/07/2020
Last Update Date	:	07/17/2023

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