Provider Demographics
NPI:1487370862
Name:WHOLEHEARTED LIVING THERAPY LICENSED PROFESSIONAL CLINICAL COUNSELOR,
Entity type:Organization
Organization Name:WHOLEHEARTED LIVING THERAPY LICENSED PROFESSIONAL CLINICAL COUNSELOR,
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIDANA
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC
Authorized Official - Phone:619-357-6986
Mailing Address - Street 1:2030 ONTARIO CT
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-4231
Mailing Address - Country:US
Mailing Address - Phone:161-976-4329
Mailing Address - Fax:
Practice Address - Street 1:2030 ONTARIO CT
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-4231
Practice Address - Country:US
Practice Address - Phone:619-357-6986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5686OtherLICENSURE NUMBER LPCC