Provider Demographics
NPI:1215356225
Name:HOLISTIC PSYCHOLOGICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:HOLISTIC PSYCHOLOGICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LICHTE-MADAKASIRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC, LMFT, RYT
Authorized Official - Phone:601-664-1001
Mailing Address - Street 1:2540 FLOWOOD DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-9362
Mailing Address - Country:US
Mailing Address - Phone:601-664-1001
Mailing Address - Fax:
Practice Address - Street 1:2540 FLOWOOD DR
Practice Address - Street 2:SUITE E
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-9362
Practice Address - Country:US
Practice Address - Phone:601-664-1001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0799261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health