Provider Demographics
NPI:1316740046
Name:AUTHENTIC SELF HOLISTIC PSYCHOTHERAPY LLC
Entity type:Organization
Organization Name:AUTHENTIC SELF HOLISTIC PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:616-498-2566
Mailing Address - Street 1:7989 MYERS LAKE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-9634
Mailing Address - Country:US
Mailing Address - Phone:616-498-2566
Mailing Address - Fax:
Practice Address - Street 1:7989 MYERS LAKE AVE NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-9634
Practice Address - Country:US
Practice Address - Phone:616-498-2566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-28
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty