Provider Demographics
NPI:1700380664
Name:HOLISTIC DRAMA LLC
Entity Type:Organization
Organization Name:HOLISTIC DRAMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZARIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:734-748-3140
Mailing Address - Street 1:15535 NORTHVILLE FOREST DR APT 251U
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4947
Mailing Address - Country:US
Mailing Address - Phone:734-748-3307
Mailing Address - Fax:
Practice Address - Street 1:340 N MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1290
Practice Address - Country:US
Practice Address - Phone:734-748-3140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-23
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006577106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty