Provider Demographics
NPI:1932834926
Name:HOLISTIC ATHLETE LLC
Entity type:Organization
Organization Name:HOLISTIC ATHLETE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC CMPC
Authorized Official - Phone:860-877-6093
Mailing Address - Street 1:24B ROSEMARY LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455-1041
Mailing Address - Country:US
Mailing Address - Phone:860-877-6093
Mailing Address - Fax:
Practice Address - Street 1:24B ROSEMARY LN
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455-1041
Practice Address - Country:US
Practice Address - Phone:860-877-6093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty