Provider Demographics
NPI:1760062723
Name:HOLISTICALLY TAILORED WELLNESS CENTER
Entity Type:Organization
Organization Name:HOLISTICALLY TAILORED WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:HALE
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:513-571-7850
Mailing Address - Street 1:312 SHARON CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-4947
Mailing Address - Country:US
Mailing Address - Phone:513-571-7850
Mailing Address - Fax:
Practice Address - Street 1:312 SHARON CT
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-4947
Practice Address - Country:US
Practice Address - Phone:513-393-9761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-13
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0441541Medicaid