Provider Demographics
NPI:1508160631
Name:WHOLE HEALTH WELLNESS, LLC
Entity Type:Organization
Organization Name:WHOLE HEALTH WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:S
Authorized Official - Last Name:BOSCO
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:860-662-1933
Mailing Address - Street 1:7 N MAIN ST UNIT 1522
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-4244
Mailing Address - Country:US
Mailing Address - Phone:860-662-1933
Mailing Address - Fax:
Practice Address - Street 1:139 MILL ROCK RD E UNIT 1522
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475
Practice Address - Country:US
Practice Address - Phone:860-662-1933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001695261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008026193Medicaid