Provider Demographics
NPI:1891397949
Name:HIATUS WELLNESS LLC
Entity type:Organization
Organization Name:HIATUS WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:DENITRA
Authorized Official - Last Name:POPOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-S
Authorized Official - Phone:512-522-9811
Mailing Address - Street 1:1205 N HWY 123 STE 305
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7756
Mailing Address - Country:US
Mailing Address - Phone:512-522-9811
Mailing Address - Fax:888-974-0284
Practice Address - Street 1:1205 N HWY 123 STE 305
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7756
Practice Address - Country:US
Practice Address - Phone:512-522-9811
Practice Address - Fax:888-974-0284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1801298344OtherNPI 1