Provider Demographics
NPI:1982469565
Name:HOLISTIC THERAPY-MIND, BODY, SPIRIT
Entity Type:Organization
Organization Name:HOLISTIC THERAPY-MIND, BODY, SPIRIT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:PETCHENIK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:847-650-4444
Mailing Address - Street 1:770 SKOKIE BLVD UNIT 845
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60062-2360
Mailing Address - Country:US
Mailing Address - Phone:847-650-4444
Mailing Address - Fax:
Practice Address - Street 1:770 SKOKIE BLVD UNIT 845
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-2360
Practice Address - Country:US
Practice Address - Phone:847-650-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-14
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty