Provider Demographics
NPI:1437838497
Name:REDEFINE LIFE HOLISTIC PSYCHOTHERAPY, LLC
Entity Type:Organization
Organization Name:REDEFINE LIFE HOLISTIC PSYCHOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSED PSYCHOTHERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERGQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DPC, LPC-S, LCDC
Authorized Official - Phone:832-781-2153
Mailing Address - Street 1:5347 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77493-2053
Mailing Address - Country:US
Mailing Address - Phone:832-781-2153
Mailing Address - Fax:
Practice Address - Street 1:5347 E 5TH ST
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77493-2053
Practice Address - Country:US
Practice Address - Phone:832-781-2153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1144679697OtherMENTAL HEALTH