Provider Demographics
NPI:1891198925
Name:WHOLISTIC LIVING, LLC
Entity Type:Organization
Organization Name:WHOLISTIC LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-937-1386
Mailing Address - Street 1:2410 CHATAU CT
Mailing Address - Street 2:
Mailing Address - City:FALLSTON
Mailing Address - State:MD
Mailing Address - Zip Code:21047-2318
Mailing Address - Country:US
Mailing Address - Phone:410-937-1386
Mailing Address - Fax:
Practice Address - Street 1:1035 EMMORTON ROAD
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014
Practice Address - Country:US
Practice Address - Phone:410-937-1386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-03
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13592101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD414765100Medicaid