Provider Demographics
NPI:1558084780
Name:EXPERIENTIAL HEALING CENTER
Entity Type:Organization
Organization Name:EXPERIENTIAL HEALING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-372-0710
Mailing Address - Street 1:1713 LOCKETT PL
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3923
Mailing Address - Country:US
Mailing Address - Phone:901-372-0710
Mailing Address - Fax:
Practice Address - Street 1:1713 LOCKETT PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-3923
Practice Address - Country:US
Practice Address - Phone:901-372-0710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty