Provider Demographics
NPI:1972270783
Name:PURPLE PETALS HEALING BAR LLC
Entity Type:Organization
Organization Name:PURPLE PETALS HEALING BAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:YARNELL
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-347-6147
Mailing Address - Street 1:3065 DANIELS RD # 1004
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-7002
Mailing Address - Country:US
Mailing Address - Phone:407-347-4164
Mailing Address - Fax:
Practice Address - Street 1:213 S DILLARD ST #220D
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787
Practice Address - Country:US
Practice Address - Phone:407-347-4164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-28
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health