Provider Demographics
NPI:1396247235
Name:EMERGING WHOLE THERAPY LLC
Entity type:Organization
Organization Name:EMERGING WHOLE THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL LMSW
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SUPERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-715-1710
Mailing Address - Street 1:9283 S NOVAK RD
Mailing Address - Street 2:
Mailing Address - City:CEDAR
Mailing Address - State:MI
Mailing Address - Zip Code:49621-9792
Mailing Address - Country:US
Mailing Address - Phone:231-715-1710
Mailing Address - Fax:
Practice Address - Street 1:820 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2466
Practice Address - Country:US
Practice Address - Phone:231-715-1710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801100021261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)