Provider Demographics
NPI:1457740888
Name:WHOLISTIC THERAPY LLC
Entity Type:Organization
Organization Name:WHOLISTIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TABETHA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MATHIESEN
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:405-795-7110
Mailing Address - Street 1:205 E CIMARRON BLVD
Mailing Address - Street 2:
Mailing Address - City:CRESCENT
Mailing Address - State:OK
Mailing Address - Zip Code:73028-9296
Mailing Address - Country:US
Mailing Address - Phone:405-795-7110
Mailing Address - Fax:
Practice Address - Street 1:1409 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-5009
Practice Address - Country:US
Practice Address - Phone:405-795-7110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3775235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty