Provider Demographics
NPI:1790416881
Name:FAMILY WHOLENESS PLLC
Entity Type:Organization
Organization Name:FAMILY WHOLENESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOPHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DYKSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:LPN, NCC, CAADC
Authorized Official - Phone:616-920-1892
Mailing Address - Street 1:1680 44TH ST SE UNIT 88333
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49518-5050
Mailing Address - Country:US
Mailing Address - Phone:214-212-2703
Mailing Address - Fax:
Practice Address - Street 1:800 MONROE AVE NW
Practice Address - Street 2:STE 202
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:214-212-2703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-21
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty