Provider Demographics
NPI:1710749015
Name:HOLISTIC FUNCTIONAL WELLNESS CENTER, PLLC
Entity Type:Organization
Organization Name:HOLISTIC FUNCTIONAL WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:347-835-2989
Mailing Address - Street 1:4501 SQUIREDALE SQ
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22309-1233
Mailing Address - Country:US
Mailing Address - Phone:347-835-2989
Mailing Address - Fax:
Practice Address - Street 1:4501 SQUIREDALE SQ
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22309-1233
Practice Address - Country:US
Practice Address - Phone:347-835-2989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty