Provider Demographics
NPI:1275284481
Name:TEA OF LIFE HOLISTIC BEHAVIORAL HEALTH THERAPY, LLC
Entity Type:Organization
Organization Name:TEA OF LIFE HOLISTIC BEHAVIORAL HEALTH THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TUNISIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONDON
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW, PIP
Authorized Official - Phone:251-401-5602
Mailing Address - Street 1:34124 BURWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORT
Mailing Address - State:AL
Mailing Address - Zip Code:36527-7301
Mailing Address - Country:US
Mailing Address - Phone:251-401-5602
Mailing Address - Fax:
Practice Address - Street 1:34124 BURWOOD DR
Practice Address - Street 2:
Practice Address - City:SPANISH FORT
Practice Address - State:AL
Practice Address - Zip Code:36527-7301
Practice Address - Country:US
Practice Address - Phone:251-401-5602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-10
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty