Provider Demographics
NPI:1457587149
Name:WHOLENESS OF LIFE SERVICES
Entity Type:Organization
Organization Name:WHOLENESS OF LIFE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELITA
Authorized Official - Middle Name:W
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:313-399-4915
Mailing Address - Street 1:23300 PROVIDENCE DR APT 401
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3626
Mailing Address - Country:US
Mailing Address - Phone:313-399-4915
Mailing Address - Fax:
Practice Address - Street 1:26847 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48240-1544
Practice Address - Country:US
Practice Address - Phone:313-399-4915
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010875701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicare PIN